Iontoforesis transdérmica con dexametasona y verapamilo para la Enfermedad de La Peyronie / Transdermal iontophoresis with dexamethasone and verapamil for Peyronie´s disease

Objetivo: Evaluar los efectos de la administración transdérmica iontoforética de verapamilo y dexametasona en pacientes con enfermedad de La Peyronie de menos de un año de evolución. Material y métodos: Tratamos a diez pacientes, dos veces a la semana durante seis semanas consecutivas, mediante un dispositivo Miniphysionizer©. Este sistema genera una corriente de 2 mA durante un ciclo de 20 min, que consigue la penetración transdérmica de la medicación. En cada sesión se administró dexametasona 8 mg y verapamilo 5 mg en un pequeño depósito autoadhesivo, pegado en la piel del pene, próximo a la placa de fibrosis. Para evaluar la eficacia del tratamiento, medimos la curvatura por el test de Kelami, y delimitamos el tamaño de la placa mediante ecografía peneana. Otros parámetros, como el dolor, la función eréctil y la capacidad para la penetración vaginal se objetivaron mediante un cuestionario. Vigilamos efectos secundarios durante el tratamiento. Resultados: No se evidenció mejoría en la desviación peneana en ninguno de los pacientes aunque tampoco hubo progresión de la misma. La consistencia de la placa de fibrosis disminuyó en 5 pacientes, llegando a no ser palpable en 2 de ellos. Se objetivó disminución del volumen medido por ecografía en 6. El dolor mejoró en 8 pacientes, llegando a desaparecer en 6 de ellos. Un paciente manifestó mejoría de la función eréctil al finalizar el tratamiento, mientras que 3 refirieron mejoría en su capacidad para la penetración y 2 que el tratamiento mejoró su vida sexual en general. No objetivamos efectos secundarios destacables, excepto un leve y transitorio eritema cutáneo en el lugar de colocación de los electrodos. Conclusión: La iontoforesis transdérmica es un tratamiento que parece eficaz para el control del dolor en los estadios iniciales de la enfermedad de La Peyronie. Su eficacia en la mejoría de la curvatura peneana parece limitada. Son necesarios ensayos clínicos controlados y tal vez revisión de sus indicaciones para conseguir efectos clínicos más relevantes (AU)

Objetives: To evaluate the effects of transdermal iontophoresis with verapamil and dexamethasone in patients with Peyronie´s disease of less than one year of evolution. Material and methods: We have treated ten patients twice a week during six consecutive weeks using iontophoresis with a Miniphysionizer© dispositive. This device generates a 2mA electric current during 20 min which triggers the transdermal penetration of medication. In every session dexamethasone 8 mg and verapamil 5mg were administered inside a small self-adhesive receptacle on the penile skin overlying the fibrosis plaque. To evaluate the efficacy, penile curvature was measured by Kelami´s test, while the plaque size was assessed by penile ultrasound. Other parameters like pain, erectile function and ability for vaginal intercourse were recorded using questionnaires. Safety parameters were also assessed during treatment. Results: No improvement or progression in penile curvature was evidenced in any of the patients. The hardness of the plaque was reduced in 5 patients, becoming impalpable in 2 of them. Decrease in plaque volume was observed by penile ultrasound in 6. Pain improved in 8 patients, disappearing in 6 of them. One patient recovered his erectile function at the end of the treatment; whereas 3 referred that their ability for intercourse enhanced while 2 reported that treatment improved their sexual life in general. We didn’t record any significantly side effects, except for a transitory and slight dermal redness on the site of electrode placement. Conclusions: Transdermal iontophoresis is an effective treatment for pain control in early stages of Peyronie´s disease. Efficacy in reducing penile curvature seems to be limited. Controlled clinical trials are needed, and perhaps reviewing indications in order to obtain more relevant clinical effects (AU)

[Hematuria and sharp renal failure as debut of secondary bladder amiloidosis. Presentation of a new case and revision of the literature]. / Hematuria y fracaso renal agudo como debut de amiloidosis vesical secundaria. Presentación de un nuevo caso y revisión de la literatura.

The primary bladder amiloidosis is an uncommon pathology, not existing in the world more than 150 published cases, being even more exceptional the secondary bladder amiloidosis being described around 25 cases. The secondary bladder amiloidosis associates in most from the patients to arthritis reumatoide of long evolution. The diagnoses clinical it is difficult, being necessary the differential diagnosis with the bladder tumour. The pathological study and inmunohistochemics, confirm the diagnosis. We present the case of a patient that I debut with frank hematuria, hemodynamic uncertainty and renal inadequacy that it required combined treatment, doctor and surgical for the resolution of their square.

[Myofibroblastic tumor of bladder]. / Tumor miofibroblástico de vejiga.

The myofibroblastic tumor, is a mesenchymal benign tumor of exceptional character, being its localization but habitual it is the lung; while its appearance in the bladder, is exceptional, not existing but of 100 published cases, of this tumor type in the bladder. This tumor type that clinic and radiologics, behave as a wicked tumor. The pathological diagnosis is complex, due to its similarity with the sarcomas, being necessary to appeal to the inmunohistochemics for a I diagnose of certainty. The treatment by means of wide resection is usually enough not existing any case of metastasis at the present time at distance, neither of malignization. We present a new case of this neoplasm, carrying out a wide bibliographical revision.

Hematuria y fracaso renal agudo como debut de amiloidosis vesical secundaria. Presentación de un nuevo caso y revisión de la literatura / Hematuria and sharp renal failure as debut of secondary bladder amiloidosis. Presentation of a new case and revision of the literature

La amiloidosis vesical primaria es una patología infrecuente, no existiendo en el mundo más de 150 casos publicados, siendo aun más excepcional la amiloidosis vesical secundaria estando descritos alrededor de 25 casos. La amiloidosis vesical secundaria se asocia en la mayor parte de los pacientes a artritis reumatoide de larga evolución. El diagnostico clínico es difícil, siendo necesario el diagnóstico diferencial con los tumores vesicales. El estudio patológico e inmunohistoquímico, confirma el diagnóstico. Presentamos el caso de una paciente que debuto con hematuria franca, inestabilidad hemodinámica e insuficiencia renal, que requirió tratamiento combinado, médico y quirúrgico para la resolución de su cuadro (AU)

The primary bladder amiloidosis is an uncommon pathology, not existing in the world more than 150 published cases, being even more exceptional the secondary bladder amiloidosis being described around 25 cases. The secondary bladder amiloidosis associates in most from the patients to arthritis reumatoide of long evolution. He diagnoses clinical it is difficult, being necessary the differential diagnosis with the bladder tumour. The pathological study and inmunohistoquímics, confirm the diagnosis. We present the case of a patient that I debut with frank hematuria, hemodynamic uncertainty and renal inadequacy that it required combined treatment, doctor and surgical for the resolution of their square (AU)

Tumor miofibroblástico de vejiga / Miofibroblastic tumor of bladder

El tumor miofibroblásticos es un tumor mesenquimal benigno de carácter excepcional, siendo su localización mas habitual es el pulmón; mientras que su aparición en la vejiga, es excepcional, no existiendo mas de 100 casos publicados, de este tipo de tumor en la vejiga. Este tipo de tumor que clínica y radiológicamente, se comporta como un tumor maligno. El diagnóstico patológico es complejo, debido a su similitud con los sarcomas, siendo necesario recurrir a la inmunohistoquímica para un diagnostico de certeza. El tratamiento mediante resección amplia suele ser suficiente no existiendo en la actualidad ningún caso de metástasis a distancia, ni de malignizacion. Presentamos un nuevo caso de este tumor, realizando una amplia revisión bibliográfica (AU)

The miofibroblastic tumor, is a mesenchimal benign tumor of exceptional character, being its localization but habitual it is the lung; while its appearance in the bladder, is exceptional, not existing but of 100 published cases, of this tumor type in the bladder. This tumor type that clinic and radiologics, behave as a wicked tumor. The pathological diagnosis is complex, due to its similarity with the sarcomas, being necessary to appeal to the inmunohistoquimics for a I diagnose of certainty.The treatment by means of wide resection is usually enough not existing any case of metastasis at the present time at distance, neither of malignization. We present a new case of this neoplasm, carrying out a wide bibliographical revision (AU)

[Transdermal iontophoresis with dexamethasone and verapamil for Peyronie's disease]. / Iontoforesis transdérmica con dexametasona y verapamilo para la enfermedad de la Peyronie.

OBJECTIVES: To evaluate the effects of transdermal iontophoresis with verapamil and dexamethasone in patients with Peyronie's disease of less than one year of evolution. MATERIAL AND METHODS: We have treated ten patients twice a week during six consecutive weeks using iontophoresis with a Miniphysionizer dispositive. This device generates a 2mA electric current during 20 min which triggers the transdermal penetration of medication. In every session dexamethasone 8 mg and verapamil 5mg were administered inside a small self-adhesive receptacle on the penile skin overlying the fibrosis plaque. To evaluate the efficacy, penile curvature was measured by Kelami's test, while the plaque size was assessed by penile ultrasound. Other parameters like pain, erectile function and ability for vaginal intercourse were recorded using questionnaires. Safety parameters were also assessed during treatment. RESULTS: No improvement or progression in penile curvature was evidenced in any of the patients. The hardness of the plaque was reduced in 5 patients, becoming impalpable in 2 of them. Decrease in plaque volume was observed by penile ultrasound in 6. Pain improved in 8 patients, disappearing in 6 of them. One patient recovered his erectile function at the end of the treatment; whereas 3 referred that their ability for intercourse enhanced while 2 reported that treatment improved their sexual life in general. We didn't record any significantly side effects, except for a transitory and slight dermal redness on the site of electrode placement. CONCLUSIONS: Transdermal iontophoresis is an effective treatment for pain control in early stages of Peyronie's disease. Efficacy in reducing penile curvature seems to be limited. Controlled clinical trials are needed, and perhaps reviewing indications in order to obtain more relevant clinical effects.

[Laparoscopic lymphadenectomy in the treatment of stage I non-seminomatous germ cell tumors]. / Linfadenectomía laparoscópica en el tratamiento de los tumores germinales no seminomatosos estadio I.

OBJECTIVE: To review the role of laparoscopic lymphadenectomy for stage I nonseminomatous germ cell tumor of the testis. METHODS: The current literature on this subject is reviewed and the advantages and disadvantages of this technique are discussed. RESULTS/CONCLUSIONS: Although there is no agreement on the management of nonseminomatous germ cell tumors of the testis, some groups advocate performing retroperitoneal lymphadenectomy after orchidectomy, particularly for tumors with a high risk of dissemination. The laparoscopic approaches that were introduced basically in the 90's, have permitted performing surgical techniques with a low morbidity and a shorter recovery time. Laparoscopic retroperitoneal lymphadenopathy is one such technique. According to the experience of several groups, this technique has an acceptable operating time (approximately 5 hours), low complication rate and short hospital stay (2-5 days according to the different series). For those with experience in performing the laparoscopic approach, it is a therapeutic alternative that should be considered for this type of testicular tumor.

[Complications of radical nephrectomy in the treatment of kidney adenocarcinoma]. / Complicaciones de la nefrectomía radical en el tratamiento del adenocarcinoma de riñón.

PURPOSE: To evaluate the peri- and post-surgical complications in Renal Adenocarcinoma (RAC) treated with Radical Nephrectomy (RN). MATERIAL AND METHOD: Revision of 109 patients with RAC who underwent transperitoneal anterior abdominal RN. Patients were locally staged post-surgically as: T1 + T2 61.5%, T3a 22.9%, T3ab 11% and T3b 4.6%. Approach and conservation of homolateral suprarenal gland were decided based on the preferences of the performing urologist. Hilar lymphadenectomy was performed in all cases. RN was done by a staff member in 77% cases and by a training resident assisted by a staff member in the remaining 23%. RESULTS: Peri-operative complications occurred in 10% patients, most commonly with left RN (13% vs. 7%) (p = 0.1), and further within this group the most frequent ones occurred in those using midpoint laparotomy (17.8% vs. 4%) (p = 0.1). Blood transfusion during surgery was required in 23% patients, this being more frequent when tumours had extended into the venous system (47%) and in left RN by midpoint laparotomy (39% vs. 12.5%) (p = 0.02). There were 32 post-surgical complications in 27 (24.8%) patients, the most common being sepsis of the surgical wound (6.4%); complications were more usual in patients undergoing right RN (31% vs. 20%) (p = 0.08) and in patients with blood transfusions (40% vs. 20%) (p = 0.4). There were no deaths. CONCLUSIONS: In our series, RN showed low intraoperative morbidity (10%), non-insignificant post-operative morbidity (24.8%) and no mortality. We consider subcostal laparotomy to be the best surgical approach in left RAC, with low morbidity and low peri-operative blood requirements.

[Endourologic treatment of ureteral ruptures in closed abdominal trauma]. / Tratamiento endourológico de las roturas ureterales en traumatismos abdominales cerrados.

The traumatic fracture of the ureter is a very uncommon entity, which accounts for 1-5% of all urological traumatism. In most cases it is secondary to penetrating lesions, endoscopic or open surgery iatrogeny, its occurrence as secondary to closed traumatism being very rare. The paper presents four patients with partial ureteral fractures caused by closed traumatism. Management was in all cases conservative with endourological methods, using backward ureteral intubation, and no case required the use of other types of complementary surgical approaches; functional recovery of urinary tract was complete in all four patients.

[Lymphocele after renal transplantation: therapeutic controversies in the age of laparoscopy]. / Linfocele postrasplante renal: controversias terapéuticas en la era de la laparoscopia.

We present 11 lymphoceles in 180 consecutive kidney transplants (6%). We study the potential etiologic factors, symptoms, diagnostic evaluation and treatment, stressing the role of laparoscopy in management of bulky and loculated symptomatic lymphoceles. This technique allows to reduce morbidity, increasing efficacy and shortening hospitalization.

[Laparoscopic bilateral nephrectomy of native kidney in kidney transplantation carriers]. / Nefrectomía bilateral laparoscópica de riñones nativos en trasplantado renal.

Severe vesicouretheral reflux sometimes causes terminal renal failure which then requires renal transplantation. In these patients it may be necessary to perform bilateral nephrectomy when associated to serious hypertension or urinary infections with a significant clinical impact. This paper presents the clinical picture of a patient with a corpse renal transplantation, due to terminal renal failure secondary to reflex nephropathy, in whom it was necessary to perform bilateral nephrectomy due to the uncommon urinary infections requiring hospitalization for treatment. The bilateral nephrectomy was done through transperitoneal laparoscopic approach, using seven points for trocars introduction. The procedure lasted 4 hours and the patients was discharged within 48 hours with no complications. Accumulate experience in the use of laparoscopy in urology has allowed this technique to be feasible. After designing the experimental model, our group has had the chance to accomplish laparoscopic nephrectomies in humans. We believe that this is the first case of bilateral nephrectomy conducted in our country using the laparoscopic approach.

[Malignant neoplasms in kidney transplant recipients]. / Neoplasias malignas en receptores de un trasplante renal.

OBJECTIVES: This study is a retrospective analysis of malignant tumors in renal transplant recipients. A review of the pertinent literature allowed us to develop a protocol for early diagnosis and treatment of tumors arising in this group of patients. METHOD: 171 renal transplants have been performed over a period of 4 years. The renal grafts had been harvested from cadavers (mean age 32.01 years). All recipients (mean age 44.3 years) were immunosuppressed with prednisone, azathioprine and cyclosporine A. RESULTS: Five "de novo" malignant tumors were detected in 4 patients (2.3%). The tumors were basal cell epithelioma of scalp and gastric adenocarcinoma in the same patient, lymphoma of the CNS, carcinoma of the breast and adenocarcinoma of the colon. The patient with a gastric adenocarcinoma died after a disease-free interval of 28 months, following treatment of the cutaneous lesion. The patient with lymphoma of the CNS had died before receiving treatment and the remaining 2 patients are disease-free at 12 and 6 months' follow-up. CONCLUSIONS: The possible role of viruses is underscored. Transplant recipients should be followed very closely since they are likely to develop a tumor, especially of skin and lips. The importance of gynecological and neurological assessment and control of native kidneys cannot be overemphasized. Performing an autopsy on donors can reduce the risk of transplanting tumors. Kidney transplantation should be delayed if the graft recipient has a tumor. Correct diagnosis and treatment will enhance the results in these patients.

[The use of kidney grafts++ from donors of the same age or below 3 years (weight equal or below 15 Kg)]. / Utilización de injertos renales de donantes de edad igual o inferior a 3 años (peso inferior o igual a 15 kgrs).

Over the last few years an impasse has been seen in the number of donors for organ transplantation. This has prompted a re-statement on the use of a group of grafts which, historically, were considered suboptimal: those from donors aged 3 years or under (weight less than or equal to 15 kg). 124 transplantations from corpse donors performed in adults over a 36 months period (Jun 90/July 93) were revised. 24 grafts (19.3%) from donors aged 3 years or under were used. Thirteen (54%) of these grafts were from donors aged 24 months or under, and six (27%) from donors aged 12 months or under. A comparative analysis is made on the clinical and functional evolution of these grafts, as well as their current survival status versus those from donors aged between 3 and 60 years (n = 86, 69.3%). Transplants made with grafts from donors older than 60 years (n = 14, 11.2%) were excluded from the analysis. Our results suggest that use of kidneys from donors aged 3 years or under--weight less than or equal to 15 kg--, implanted as units is acceptable when compared to grafts from older donors. Considering the current impasse in donations for organ transplantation we believe use of this type of donors, as a useful source of grafts, should be advocated.

[Retroperitoneal laparoscopic nephrectomy: a case report]. / Nefrectomía laparoscópica por vía retroperitoneal: caso report.

Presentation of the first exclusively retroperitoneal laparoscopic nephrectomy performed on a female patient diagnosed with chronic pyelonephritis in the right kidney who referred frequent discomfort in the ipsilateral lumbar fossa as well as sporadic urinary infections. The entire procedure was performed without entering the peritoneal cavity, creating a space in the retroperitoneum, using for that hydrostatic dilation following Gaur's recommendations and introducing in that space a total of 4 trocars. Surgery lasted 3 hours an 35 minutes, with a post-operative stay of 3 days; the anaesthetics used after surgery was minimum and patient's return to her usual daily activities was almost immediate after discharge. Considering our group's previous experience in laparoscopic nephrectomies, both in humans (another 3 cases) and experimental surgery (18 pigs), we believe retroperitoneal approach is a huge step ahead in urological laparoscopic surgery, since this is the typical approach in our specialty and allows a closer contact with the condition being treated. On the other hand, the combined retro- and transperitoneal accesses will involve-are already involving-a greater variety of laparoscopic techniques in urology.

[Reliability of CAT in the local staging of tumors of the upper urothelium]. / Fiabilidad de la TAC en el estadiaje local de los tumores del urotelio superior.

Presentation of a retrospective study where the reliability of computerized axial tomography (CAT) used in preoperative local diagnostic definition of 20 upper urothelium tumours (UUT) radically treated between 1985 and 1991 is analyzed. Of them, only 70% were located by CAT and, of these, only 56% (45% of total) obtained a clear correlation with their local infiltration stage. Thus, it is concluded that CAT alone is not a good method for the preoperative evaluation of UUTs, at least when it comes to indicate their likely conservative treatment.

[Initial treatment of pyonephrosis using percutaneous nephrostomy. Value of the technique]. / Tratamiento inicial de la pionefrosis mediante nefrostomía percutánea. Valor de la técnica.

Until early in the eighties, the initial treatment of choice for pyonephrosis was by emergency surgical excision, which carried a high intraoperative and early postoperative morbidity and mortality. The introduction of percutaneous nephrostomy, a technique with a low complication rate that permits easy access in dilated excretory tracts and is highly effective, as shown by the clinical and analytical course of the patients with pyonephrotic kidney and by the number of nephrectomies performed, represented a substantial change in the initial therapeutic approach. The present article reports our experience of 123 percutaneous nephrostomies performed in 118 pyonephrotic kidneys over a period of 10 years, which constitutes one of the largest series reported in the literature. The clinical features and the findings disclosed by imaging techniques that permit making the diagnosis are presented. We describe the PCN procedure and its advantages, with special reference to the reduced morbidity and mortality, particularly in those cases complicated by septic shock. The procedure also permits evaluation of the underlying obstructive uropathy and function of the compromised kidney, therefore more renal units can be preserved, nephrectomy can be avoided and morbidity is minimal. For all the foregoing reasons, PCN guided by an imaging technique is currently the most effective initial treatment of pyonephrosis.

[Transcatheter arterial embolization in the hemorrhagic complications of kidney trauma]. / Embolización arterial transcatéter en las complicaciones hemorrágicas del trauma renal.

Transcatheter arterial embolization is a nonsurgical alternative for the complications arising from biopsy, surgery and blunt or penetrating renal trauma. Fourteen transcatheter embolization procedures were performed in 13 patients for hemorrhage following biopsy of the native kidney (3 cases) biopsy of the transplanted kidney graft (3 cases), stone surgery (3 cases), blunt abdominal trauma (2 cases), a stab wound (1 case) and an A-V fistula (1 case). The bleeding was effectively controlled in all cases. Nephrectomy was required in 3 cases (21.4%) whose kidneys were not viable and cannot be ascribed to a complication of the embolization procedure. The diagnostic aspects of hemorrhage arising from renal trauma, the embolization technique and its indications are discussed. In our view, transcatheter arterial embolization is the technique of choice for the hemorrhagic complications of blunt or penetrating renal trauma or those caused by biopsy or surgery.

[Urethral sonography in the diagnosis and preoperative evaluation of urethral stenosis]. / Sonouretrografía en el diagnóstico y evaluación preoperatoria de la estenosis de uretra.

An area of spongiofibrosis can be found proximal and distal to all stenosis of the urethra. The severity of such spongiofibrosis as well as its length are in many instances decisive when choosing an adequate surgical approach. Conventional radiological diagnosis of stenosis of the urethra only shows the area of urethral stricture but is unable to inform on the fibrosis of the spongy body. Sonourethrography or urethral echography affords a dynamic tridimensional examination of the anterior urethra which provides accurate data on the length of the stenosis, as well as the extend and severity of the spongiofribosis. Sixteen patients diagnosed with stenosis of the urethra through sonourethrography were evaluated. This easy-to-perform investigation, allowed the identification of 4 patients with peristenotic intense spongiofibrosis, hypercongenital urethra, who underwent open urethroplastia. The urethra of another 3 patients showed normal echogenicity, but diminished elasticity, and were diagnosed as of moderate spongiofibrosis requiring extensive internal urethrotomy. We believe sonourethrography should become a procedure to be included as part of the routine pre-surgical investigation of the stenosis of the urethra due to its non-invasive nature, easiness to perform, and because it provides highly useful information which would allow a decreased number of re-stenosis following surgery of the urethral stenosis.

[Current treatment of ureteral lithiasis. Review of our experience]. / Tratamiento actual de la litiasis ureteral. Revisión de nuestra experencia.

Retrospective analysis from June '89 to January '91 of 198 patients seen in our Hospital for ureteral lithiasis using 'in situ' ESWL as the first therapeutic choice. The number of sessions per calculus was 1.45, 68.7% cases receiving only one session. 84.2% calculi were resolved by ESWL, with associated instrumental manoeuvres in less than 15% cases. Our hospital's therapeutic algorithm for the 15.8% calculi where ESWL failed is presented. The conclusion is that 'in situ' shock wave extracorporeal lithotripsy represents a perfectly valid alternative for the treatment of ureteral lithiasis regardless its location.