[Urology clinics referral Patterns after initiation of a Primary Care BPH-LUTS protocol.] / Evolución de las derivaciones desde atención primaria a la consulta de urología tras la aplicación de un protocolo de pacientes con síntomas del tracto urinario inferior por hiperplasia benigna de próstata.

OBJECTIVE: In the Spanish health system, General Practitioners (GPs) play a key role in regulating the flow of patients to hospital care. Most of patients with BPH can be managed through out the evolution of the disease exclusively by the GPs.  METHODS: A pre-experimental study was carried outin two periods, before (pre-test) and after (post-test) of the dissemination of a management protocol for patients with BPH. The protocol was trialled in the health area of Villarrobledo and included all referrals to the urology clinic for BPH from Primary Care. We analyzed the appropriate referrals according with the criteria set for thin the protocol and compared the complementary tests through statistical study (descriptive, a bivariate, multivariate analysis and rate calculation) using version 21of the SPSS. RESULTS: Referral rate decreased after the application of the protocol but did not increase the rate of appropriated referrals. Patients referred after setting forth protocol by GPs that assisted to the education program were younger. There were referred less patients with elevated PSA and more patients with clinical progression. These GPs used less test to achieve diagnosis. The GPs whodid not attend were significantly younger, mainly women, with no previous specific training in BPH and without a full time GP position. CONCLUSIONS: The implementation of a protocol has reduced the referral rate, but it has not improved the appropriate referrals. More research is required to understand the determinants of inequalities in referral from primary care.

OBJETIVO: Los médicos de Atención Primaria (MAP) son fundamentales en la regulación del flujo de pacientes desde Atención Primaria (AP), por tanto,es esencial buscar métodos de adecuada gestión de la demanda asistencial y así optimizar recursos. En la hipertrofia benigna de próstata (HBP) se estima que 2/3 de los pacientes pueden ser manejados íntegramentedesd e AP a lo largo de todo el proceso de la HBP.MATERIAL Y MÉTODOS: Hemos realizado un estudio pre experimental en dos períodos, antes (pre-test) y después (post-test) de la creación de un protocolo de manejo y derivación de pacientes con HBP. Analizamos la adecuación a los criterios de derivación y el uso de los estudios complementarios para llevar a cabo el diagnóstico, realizando un análisis estadístico (descriptivo, bivariante, multivariante y cálculo de tasas) utilizando SPSS (versión 21). RESULTADOS: La tasa de derivación disminuyó tras la aplicación del protocolo, pero no logró mejorar la adecuación. Los pacientes derivados por los MAP que asistieron al programa educativo fueron más jóvenes. Se remitieron menos pacientes con PSA elevado y más pacientes con progresión clínica. Se utilizaron menos estudios complementarios. Los MAP que no acudieron a la formación eran más jóvenes, principalmente mujeres, sin formación especifica en HBP y con contrato temporal. CONCLUSIONES: A pesar de reducir la tasa de derivación no se consiguió mejorar la adecuación de la derivación de los pacientes. Consideramos necesario analizar la problemática de los MAP y valorar otras intervenciones que podrían mejorar la calidad en la transferencia de responsabilidades.

Evolución de las derivaciones desde atención primaria a la consulta de urología tras la aplicación de un protocolo de pacientes con síntomas del tracto urinario inferior por hiperplasia benigna de próstata / Urology clinics referral Patterns after initiation of a Primary Care BPH-LUTS protocol

OBJETIVO: Los médicos de Atención Primaria (MAP) son fundamentales en la regulación del flujo de pacientes desde Atención Primaria (AP), por tanto, es esencial buscar métodos de adecuada gestión de la demanda asistencial y así optimizar recursos. En la hipertrofia benigna de próstata (HBP) se estima que 2/3 de los pacientes pueden ser manejados íntegramente desde AP a lo largo de todo el proceso de la HBP. MATERIAL Y MÉTODOS: Hemos realizado un estudio pre experimental en dos períodos, antes (pre-test) y después (post-test) de la creación de un protocolo de manejo y derivación de pacientes con HBP. Analizamos la adecuación a los criterios de derivación y el uso de los estudios complementarios para llevar a cabo el diagnóstico, realizando un análisis estadístico (descriptivo, bivariante, multivariante y cálculo de tasas) utilizando SPSS (versión 21). RESULTADOS: La tasa de derivación disminuyó tras la aplicación del protocolo, pero no logró mejorar la adecuación. Los pacientes derivados por los MAP que asistieron al programa educativo fueron más jóvenes. Se remitieron menos pacientes con PSA elevado y más pacientes con progresión clínica. Se utilizaron menos estudios complementarios. Los MAP que no acudieron a la formación eran más jóvenes, principalmente mujeres, sin formación especifica en HBP y con contrato temporal. CONCLUSIONES: A pesar de reducir la tasa de derivación no se consiguió mejorar la adecuación de la derivación de los pacientes. Consideramos necesario analizar la problemática de los MAP y valorar otras intervenciones que podrían mejorar la calidad en la transferencia de responsabilidades

OBJECTIVE: In the Spanish health system, General Practitioners (GPs) play a key role in regulating the flow of patients to hospital care. Most of patients with BPH can be managed throughout the evolution of the disease exclusively by the GPs. METHODS: A pre-experimental study was carried out in two periods, before (pre-test) and after (post-test) of the dissemination of a management protocol for patients with BPH. The protocol was trialled in the health area of Villarrobledo and included all referrals to the urology clinic for BPH from Primary Care. We analyzed the appropriate referrals according with the criteria set forth in the protocol and compared the complementary tests through statistical study (descriptive, a bivariate, multivariate analysis and rate calculation) using version 21 of the SPSS. RESULTS: Referral rate decreased after the application of the protocol but did not increase the rate of appropriated referrals. Patients referred after setting forth protocol by GPs that assisted to the education program were younger. There were referred less patients with elevated PSA and more patients with clinical progression. These GPs used less test to achieve diagnosis. The GPs who did not attend were significantly younger, mainly women, with no previous specific training in BPH and without a full time GP position. CONCLUSIONS: The implementation of a protocol has reduced the referral rate, but it has not improved the appropriate referrals. More research is required to understand the determinants of inequalities in referral from primary care

Analysis of the Efficacy of a Sublingual Bacterial Vaccine in the Prophylaxis of Recurrent Urinary Tract Infection.

OBJECTIVES: Recurrent urinary tract infections (R-UTIs) are very common amongst women, and alternatives to antibacterial prophylaxis are necessary. This study evaluates the effectiveness of a sublingual bacterial vaccine for the prophylaxis of R-UTIs. METHODS: We conducted a quasi-experimental pretest-posttest study of 166 women diagnosed with R-UTIs. Both before and after the start of treatment with the vaccine, we analysed the total number of R-UTI episodes, the urine culture results, and the type and number of antibiotic packages consumed. Symptoms and urine cultures were evaluated 3, 6, 9, 12, 18, and 24 months after initiating treatment with the vaccine. RESULTS: The mean time of follow-up after vaccination was 1.7 years. After vaccination, there was a 54.6% reduction in episodes of UTI, and a 56.2% reduction in positive urine cultures. At 3 months, 74.4% of the patients had no R-UTI, the rate falling to 68.1% at 6 months, 52.4% at 12 months, and 44.5% at 24 months. The cumulative probability of maintaining negative urine cultures was 76% at 3 months, 37% at 12 months, and 18% at 2 years. CONCLUSIONS: The use of a sublingual bacterial vaccine for the prophylaxis of R-UTIs in women is an effective treatment that contributes to a reduction in the number of UTI episodes.

Metástasis cutánea de carcinoma urotelial de vejiga. Presentación de un caso / Cutaneous metastasis of urothelial carcinoma of the bladder. Case report

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Multilocular cystic nephroma: A clinical case.

OBJECTIVE: To describe the clinical presentation, preoperative diagnostic possibilities, and treatment of cystic nephroma. METHODS: We describe a case of cystic nephroma in an adult male and show that, both in our patient and in the literature, a definitive diagnosis can only be obtained postoperatively, even when there is a reasonable clinical suspicion. CONCLUSIONS: Cystic nephroma is rare, and some authors consider it a questionable entity. However, it should be distinguished from renal cystic neoplasms, which can resemble the condition.

Nefroma quístico multilocular: a propósito de un caso / Multilocular cystic nephroma: A clinical case

OBJETIVO: Mostrar la presentación clínica, las posibilidades diagnosticas preoperatorias y el tratamiento del nefroma quístico. MÉTODOS: Se presenta un caso de nefroma quístico en un varón adulto, comprobando en nuestro caso y en la revisión de la literatura que aunque exista una razonable sospecha clínica, el diagnóstico cierto solo es posible postcirugía. CONCLUSIONES: El nefroma quístico es de frecuencia escasa y por algunos autores es considerada una entidad dudosa, pero hay que tratar de distinguirla de neoplasias quísticas renales, que pueden simular este proceso

OBJECTIVE: To describe the clinical presentation, preoperative diagnostic possibilities, and treatment of cystic nephroma.METHODS: We describe a case of cystic nephroma in an adult male and show that, both in our patient and in the literature, a definitive diagnosis can only be obtained postoperatively, even when there is a reasonable clinical suspicion.CONCLUSIONS: Cystic nephroma is rare, and some authors consider it a questionable entity. However, it should be distinguished from renal cystic neoplasms, which can resemble the condition

Paraurethral leiomyoma.

OBJECTIVE: To describe a case of para-urethral leiomyoma and to review the literature. METHODS: The usual preoperative diagnostic procedures and clinical manifestations are discussed. RESULTS: The mass was resected and, 6 years later, the patient remains asymptomatic and with no recurrence. CONCLUSIONS: Urethral or paraurethral leiomyomas are benign tumors that arise from the urethral or vaginal smooth muscle. Radiological findings (particularly magnetic resonance imaging) may suggest the origin of the tumor before surgery; however, the final diagnosis is determined by histology.

Leiomioma parauretral / Paraurethral Leiomyoma

OBJETIVO: Presentar un caso de leiomioma parauretral y revisar la literatura. MÉTODOS: Se comentan los procedimientos diagnósticos preoperatorios más habituales y las manifestaciones clínicas. RESULTADOS: Tras la exéresis de la tumoración la paciente quedó asintomática, y sin recidiva seis años después. CONCLUSIONES: Los leiomiomas uretrales o parauretrales son tumoraciones benignas derivadas del músculo liso uretral o vaginal, siendo posible intuir preoperatoriamente este origen con pruebas radiológicas especialmente con la RMN, aunque el diagnostico definitivo solo es histológico (AU)

OBJECTIVE: To describe a case of para-urethral leiomyoma and to review the literature. METHODS: The usual preoperative diagnostic procedures and clinical manifestations are discussed. RESULTS: The mass was resected and, 6 years later, the patient remains asymptomatic and with no recurrence. CONCLUSIONS: Urethral or paraurethral leiomyomas are benign tumors that arise from the urethral or vaginal smooth muscle. Radiological findings (particularly magnetic resonance imaging) may suggest the origin of the tumor before surgery; however, the final diagnosis is determined by histology (AU)

Supernumerary testicle: case report and bibliographic review.

OBJECTIVE: We report a case of supernumerary testis, a rare anomaly with only around 100 cases reported in the literature. METHODS: We describe the case of a 26-year-old man who consulted for a left paratesticular tumor. Physical examination and ultrasound showed a 2-cm nodular lesion over the left epididymis. The lesion was confirmed as supernumerary testis by surgical examination and biopsy and was subsequently excised, given the malignancy potential. RESULTS: The supernumerary testis was evaluated using two standard classifications, one assessing function and embryological development, and the other assessing topography, anatomy, and reproductive potential. CONCLUSIONS: The differential diagnosis for an intrascrotal mass should include the possibility of a supernumerary testis; hence, surgical examination and biopsy are necessary. Supernumerary testes should be excised in the case of pain, dysplasia, or in situ carcinoma, or whenever the biopsy is inconclusive.

Poliorquia: presentación de un caso y revisión de la literatura / Supernumerary testicle: case report and bibliographic review

OBJETIVO: Presentar un caso de teste supernumerario, rara anomalía de la que existen descritos y fundamentados aproximadamente 120 casos. MÉTODOS: Presentamos el caso de un varón de 26 años que consultó por presentar tumoración paratesticular izquierda. La exploración física y ecográfica evidenciaron una lesión nodular de aproximadamente 2 cm sobre epidídimo izquierdo que se confirmaría posteriormente durante la exploración quirúrgica y biopsia. Dada la posibilidad de malignización se decidió extirpar el teste supernumerario. RESULTADOS: Para evaluar un teste supernumerario disponemos de varias clasificaciones que evalúan la funcionalidad y el desarrollo embriológico del mismo, así como la topografía, la anatomía y su potencial reproductivo. CONCLUSIONES: Ante una masa intraescrotal debemos tener en cuenta a la hora de realizar el diagnóstico diferencial la presencia de un teste supernumerario, siendo fundamental la exploración quirúrgica y biopsia. Realizaremos exéresis del teste supernumerario siempre que sea origen de dolor, displasia, carcinoma in situ, o la biopsia arroje dudas(AU)

OBJECTIVE: We report a case of supernumerary testis, a rare anomaly with only around 100 cases reported in the literature. METHODS: We describe the case of a 26-year-old man who consulted for a left paratesticular tumor. Physical examination and ultrasound showed a 2-cm nodular lesion over the left epididymis. The lesion was confirmed as supernumerary testis by surgical examination and biopsy and was subsequently excised, given the malignancy potential. RESULTS: The supernumerary testis was evaluated using two standard classifications, one assessing function and embryological development, and the other assessing topography, anatomy, and reproductive potential. CONCLUSIONS: The differential diagnosis for an intrascrotal mass should include the possibility of a supernumerary testis; hence, surgical examination and biopsy are necessary. Supernumerary testes should be excised in the case of pain, dysplasia, or in situ carcinoma, or whenever the biopsy is inconclusive(AU)

Tratamiento quirúrgico de adenomas adrenales / Surgical treatment of adrenal adenoma

Presentamos nuestra casuística de 60 adrenalectomías por adenoma, desde febrero de 1993 hasta enero de 2010, determinando los aspectos clínicos y patológicos más importantes desde el punto de vista quirúrgico, comparando la técnica laparoscópica respecto a la cirugía abierta. Material y métodos: Estudio retrospectivo observacional valorando características clínicas y hormonales, destacando las variables relacionadas con la cirugía (tamaño y localización del tumor, tipo y duración de la cirugía, tipo de incisión), incidencias intra operatorias, pérdidas hemáticas, datos anatomo patológicos (peso, tamaño y confirmación microscópica), complicaciones pos operatorias. Resultados: De los 60 pacientes, 24 eran hombres y 36 mujeres, con una edad media de 52,5 años (79,3 - 8,1). Todos ellos fueron diagnosticados anatomo patológicamente de adenoma adrenal siendo 50 adenomas funcionantes frente a 10 no funcionantes. De los adenomas funcionantes se establecieron los siguientes diagnósticos: 34 de síndrome de Con (56,6 por ciento), 15 casos de síndrome de Cushing (25 por ciento) y 1 síndrome adrenogenital (1,6 por ciento). La localización predominante fue la izquierda con 38 casos (63,3 por ciento) frente a la derecha con 22 casos (36,6 por ciento).En 39 pacientes se realizó adrenalectomía laparoscópica transperitoneal, mientras que en los 21 pacientes restantes se realizó cirugía abierta. La duración quirúrgica media fue de 147 minutos (230-50). El tamaño medio de la pieza quirúrgica fue de 3,27 cm (8-0,7). La estancia media hospitalaria fue de 6,4 días (20-2). Entre las complicaciones destacaron dos neumotórax, una angina de pecho, una neumonía nosocomial y dos pacientes que precisaron reintervención a las 24 horas de la cirugía por hemorragia y shock hipovolémico. Conclusiones: Debe considerarse la adrenalectomía laparoscópica unilateral como el tratamiento de elección del adenoma adrenal...

We present our series of sixty adrenalectomy for adrenal adenoma, from February 1993until January 2010, determining the most important clinical and pathological aspects from a surgical point of view. We compare the laparoscopic approach with open surgery. Material and methods: Retrospective observational study evaluating clinical and hormonal characteristics. We highlight the surgery-related variables (tumor size and location, type and duration of surgery, type of incision), intraoperative events, blood loss, histological findings (weight, size and microscopic confirmation) and postoperative complications. Results: Total number of 60 patients, 24 were men and 36 women with a mean age of 52.5 years (79.3to 8.1). All of them were histologically diagnosed of adrenal adenoma. 50 were functioning adenomas (10 non-functioning) with the final following diagnoses: 34 Conn’s syndrome (56,6 percent), 15 Cushing’s syndrome (25percent) and 1 adrenogenital syndrome (1,6 percent). The primary side was left with 38 cases(63,3 percent) compared to the right side with 22 cases (36,6 percent).Thirty-nine patients (65 percent) underwent transperitoneal laparoscopic adrenalectomy, while the remaining 21 patients had open surgery. The average operating time was 147 minutes (230-50). The mean sizeof the specimen was 3.27 cm (8-0.7). The average hospital stay was 6.4 days (20 - 2). The most important complications were: two pneumothorax, one angina pectoris, a nosocomial pneumonia and two patients who were reoperated 24 hours after surgery due to hemorrhage and hypovolemic shock. Conclusion: Unilateral laparoscopic adrenalectomy should be considered as the treatment of choice for adrenal adenoma, as it is a safe surgical technique with a low complication rate. It allows a shorter hospital stay and a more rapid incorporation into everyday life...

Cuerpo extraño intravesical / Bladder foreign body

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46,XX T testicular disorder of sex development. Case report.

OBJECTIVE: We present a case of X-Y translocation with male phenotype (46,XX testicular disorder of sex development) and review the literature. METHODS: Disorders of sex development with mismatch of genetic, gonadal and phenotypic sex are quite rare, and some are due to genetic or chromosomal abnormalities. The karyotype was investigated by a cytogenetic study of peripheral blood (phytohemagglutinin-timulated lymphocyte culture over 72 hours). G-banding analysis of 25 metaphases showed a 46,XX chromosome constitution (46 chromosomes with XX sexual composition). Fluorescence in situ hybridization (FISH) analysis with probes for X centromeres and the sex-determining region of the Y chromosome (SRY) (testis-determining factor gene) showed two X chromosomes. The analysis also showed the SRY signal in the telomeric region of the short arm of one of the chromosomes. RESULTS: In recent years, a number of other genes involved in disorders of sex development in animals and humans have also been identified. Genetic defects in the peptide hormone receptors, members of the steroid receptor superfamily, and other transcription factors, as well as any of a series of enzymes and cofactors involved in steroid biosynthesis can cause abnormal determination and differentiation. CONCLUSIONS: Although chromosomal abnormalities are rarely present in patients with apparently normal external genitalia, they should be considered in urology consultations by adolescents and adults, particularly in the investigation of gynecomastia or infertility.

46, XX testicular DSD. Aportación de un caso / 46, XX testicular disorder of sex development. Case report

OBJETIVO: Presentamos un caso de translocación entre cromosomas X e Y, con fenotipo masculino (46,XX testicular DSD) y revisamos la literatura.MÉTODOS: Los trastornos de la diferenciación sexual en los que no hay correspondencia entre los sexos genético, gonadal y fenotípico son relativamente infrecuentes, algunos son debidos a alteraciones genéticas o cromosómicas.Se efectuó estudio citogenético, realizando cariotipo en sangre periférica (cultivo de linfocitos de 72 horas de duración estimulados por fitohemaglutinina). Las 25 metafases analizadas con bandas G muestran una formula cromosómica de 46,XX (46 cromosomas con formula sexual XX). Tras realizar FISH (hibridación “in situ” fluorescente) con sondas para centrómero de X y región SRY(gen determinante de testículos) de Y, se observan dos cromosomas X, y en la región telomérica del brazo corto de uno de ellos la señal para SRY.RESULTADOS: En los últimos años se han identificado varios genes a parte del SRY, en animales y en humanos que intervienen en los trastornos de la diferenciación sexual. Los defectos genéticos en los receptores de las hormonas péptidicas, los miembros de la superfamilia de los receptores esteroideos y otros factores de transcripción, así como cualquiera de una serie de enzimas y cofactores que intervienen en la biosíntesis de los esteroides pueden inducir una determinación y una diferenciación anómala.CONCLUSIONES: Aunque son poco frecuentes las alteraciones cromosómicas con genitales externos aparentemente normales, hay que tenerlas en cuenta sobre todo en la consulta de urología de adolescentes y adultos, fundamentalmente en el estudio de ginecomastia o de infertilidad(AU)

OBJECTIVE: We present a case of X-Y translocation with male phenotype (46,XX testicular disorder of sex development) and review the literature.METHODS: Disorders of sex development with mismatch of genetic, gonadal and phenotypic sex are quite rare, and some are due to genetic or chromosomal abnormalities. The karyotype was investigated by a cytogenetic study of peripheral blood (phytohemagglutinin-stimulated lymphocyte culture over 72 hours). G-banding analysis of 25 metaphases showed a 46,XX chromosome constitution (46 chromosomes with XX sexual composition). Fluorescence in situ hybridization (FISH) analysis with probes for X centromeres and the sex-determining region of the Y chromosome (SRY) (testis-determining factor gene) showed two X chromosomes. The analysis also showed the SRY signal in the telomeric region of the short arm of one of the chromosomes.RESULTS: In recent years, a number of other genes involved in disorders of sex development in animals and humans have also been identified.Genetic defects in the peptide hormone receptors, members of the steroid receptor superfamily, and other transcription factors, as well as any of a series of enzymes and cofactors involved in steroid biosynthesis can cause abnormal determination and differentiation.CONCLUSIONS: Although chromosomal abnormalities are rarely present in patients with apparently normal external genitalia, they should be considered in urology consultations by adolescents and adults, particularly in the investigation of gynecomastia or infertility(AU)

Vaginal metastasis of a clear renal cell carcinoma.

OBJECTIVE: Remember that kidney cancer is a disease whose incidence is increasing due to increased use of additional imaging tests, which is changing the way of diagnosis, making the classic clinical syndrome synonymous with advanced illness. METHODS: We report the case of a patient with a right renal tumor with renal vein involvement that in the natural course of the disease showed a vaginal metastasis of clear renal cell carcinoma, which was treated with surgical excision. RESULTS: This case is a clear example of how unpredictable is the clinical evolution of this disease and how little we know about the way of dissemination. CONCLUSIONS: Local excision, with or without radiotherapy, or radiotherapy alone are recommended in cases of unique metastasis after nephrectomy.

Metástasis en vagina de tumor renal de células claras / Vaginal metástasis of a clear renal cell carcinoma

OBJETIVO: Recordar que el cáncer renal es una enfermedad cuya incidencia está en aumento debido al mayor uso de pruebas complementarias, lo cual está modificando el modo de diagnóstico, convirtiendo a la clínica clásica en sinónimo de enfermedad avanzada.MÉTODO: Presentamos un caso clínico de una paciente con un tumor renal derecho con afectación de la vena renal intervenido, que en la evolución natural de la enfermedad presentó metástasis vaginal del tumor de células claras; las cuales fueron tratadas con exéresis quirúrgica. RESULTADO: Este caso es un claro ejemplo de lo poco previsible de la evolución clínica y de lo poco esclarecido que está el modo de diseminación de esta enfermedad.CONCLUSIÓN: La excisión local, asociada o no de radioterapia, o la radioterapia sola son las terapias aconsejadas en los casos de aparición de metátasis únicas tras la nefrectomía(AU)

OBJECTIVE: Remember that kidney cancer is a disease whose incidence is increasing due to increased use of additional imaging tests, which is changing the way of diagnosis, making the classic clinical syndrome synonymous with advanced illness.METHODS: We report the case of a patient with a right renal tumor with renal vein involvement that in the natural course of the disease showed a vaginal metastasis of clear renal cell carcinoma, which was treated with surgical excision.RESULTS: This case is a clear example of how unpredictable is the clinical evolution of this disease and how little we know about the way of dissemination.CONCLUSIONS: Local excision, with or without radiotherapy, or radiotherapy alone are recommended in cases of unique metastasis after nephrectomy(AU)

Avulsión genital / Genital avulsion

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