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...

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)

Quistes de rafe medio. Aportacion de dos casos revisión de laliteratura / Median Raphe Cyst. Report of two cases and literature review

OBJETIVOS: Presentar dos casos de quistes de rafe medio, uno de localización peneana y otro perineal.MÉTODO: Se diagnostican y describen dos casos de quiste de rafe medio, a uno se aplicó tratamiento quirúrgico y el segundo no precisó de tratamiento alguno.RESULTADOS: La intervención quirúrgica del paciente operado no tuvo complicaciónes y a los dos años de la misma estaba asintomático y sin recidiva.CONCLUSIÓN: Los quistes de rafe medio son poco frecuentes; es una patología benigna y su etiología no está completamente aclarada. Su tratamiento consiste en la exéresis simple(AU)

OBJECTIVES: To report 2 cases of median raphe cysts, 1 in the penis and the other in the perineum.METHOD: Two cases of median raphe cyst are described; the first was treated by surgery and the second required no treatment.RESULTS: The surgical patient experienced no complications and was asymptomatic with no recurrence at 2 years.CONCLUSIONS: Median raphe cysts are a rare, benign condition of uncertain etiology. Treatment consists on simple excision(AU)

[Spermatic cord sarcomas: current status and report of four cases]. / Sarcomas de cordón espermático: estado actual y presentación de cuatro casos clínicos.

OBJECTIVE: To study and review spermatic cord sarcomas, including symptoms, diagnosis, and treatment. METHODS/RESULTS: We review the Spanish and international literature and report 4 new cases: 2 patients with well-differentiated spermatic cord liposarcomas (1 treated by simple tumorectomy), 1 patient with liposarcomatous degeneration of a previously excised atypical lipoma, and 1 patient operated for a malignant retroperitoneal fibrous histiocytoma with subsequent local recurrence in the paratesticular region. CONCLUSIONS: Spermatic cord sarcomas are rare entities that usually appear as painless paratesticular mass. They are diagnosed by imaging studies (ultrasound, computed tomography, magnetic resonance) and confirmed by histological examination. Spermatic cord sarcomas are treated surgically; the efficacy of adjuvant treatments such as chemotherapy or radiation therapy is still under debate.

Sarcomas de cordón espermático estado actual y presentación de cuatro casos clínicos / Spermatic cord sarcomas: current status and report of four cases

OBJETIVO: Estudio y revisión de los sarcomas de cordón espermático, de la clínica, diagnóstico y tratamiento de dicha patología.MÉTODOS/ RESULTADOS: Se revisa la literatura nacional e internacional, aportando cuatro nuevos casos: dos liposarcomas de cordón espermático bien diferenciados, uno de ellos tratado mediante tumorectomía simple; un paciente con degeneración liposarcomatoide de un lipoma atípico previo resecado; y otro paciente intervenido de un fibrohistiocitoma maligno retroperitoneal con posterior recidiva local a nivel de la región paratesticular.CONCLUSIONES: Los sarcomas de cordón espermático son una entidad poco frecuente que habitualmente se manifiestan como una masa paratesticular indolente. Su diagnóstico se efectúa mediante métodos de imagen (ecografía, TAC, RNM) y se confirma mediante el estudio histológico. El tratamiento es quirúrgico, existiendo cierta controversia acerca de la eficacia de tratamientos adyuvantes como la quimioterapia o la radioterapia(AU)

OBJECTIVE: To study and review spermatic cord sarcomas, including symptoms, diagnosis, and treat-ment.METHODS/RESULTS: We review the Spanish and international literature and report 4 new cases: 2 patients with well-differentiated spermatic cord liposarcomas (1 treated by simple tumorectomy), 1 patient with liposarcomatous dege-neration of a previously excised atypical lipoma, and 1 pa-tient operated for a malignant retroperitoneal fibrous histio-cytoma with subsequent local recurrence in the paratesticular region.CONCLUSIONS: Spermatic cord sarcomas are rare entities that usually appear as painless paratesticular mass. They are diagnosed by imaging studies (ultrasound, computed tomography, magnetic resonance) and confirmed by histological examination. Spermatic cord sarcomas are treated surgically; the efficacy of adjuvant treatments such as chemotherapy or radiation therapy is still under debate(AU)

Tumor testicular bilateral sincrónico de distancia histología / Bilateral synchronic testicular tumor of different histology

Objetivo: Presentar el caso de un tumor testicular germinal bilateral sincrónico de distinta histología. Método/ Resultado: Se trata de un paciente de 37 años que durante un estudio ecográfico, por sospecha de tumor testicular izquierdo, se apreció una tumoración testicular contralateral sincrónica. Se practicó orquiectomía inguinal bilateral y en el posterior estudio anatomopatológico se confirmó la presencia de la tumoración testicular bilateral de distinto componente histológico. Conclusión: Alrededor del 75% de los casos de tumoración testicular bilateral son metacrónicos, presentándose únicamente el 10% con diferente histología. El tipo histológico suele correlacionarse con el aspecto ecográfico, y el tratamiento de elección de un paciente con patología oncológica de este tipo es la orquiectomía inguinal bilateral (AU)

Objective: To report one case of bilateral synchronic germ cell testicular tumour of different histology. Methods/Results: 37-year-old patient with left testicular tumor under study was found to have a contralateral synchronic testicular tumor on ultrasound. Bilateral inguinal orchiectomy was performed and pathology reported the presence of bilateral testicular tumours of different histological type. Conclusions: Around 75% of the cases of bilateral testicular tumours are metachronic, with only 10% presenting different histology. Histological type often correlates with the ultrasound findings, and the treatment of choice in patients with this type of oncological pathology is bilateral inguinal orchiectomy (AU)

[Ambulatory surgery in a urology department. Analysis of the period 2003-2006]. / Cirugía ambulatoria en un Servicio de Urología. Análisis del período 2003-2006.

OBJECTIVES: When talking about day surgery we have to differentiate between minor and major ambulatory surgery. Ambulatory surgery enables the patient to stay in the hospital not more than a few hours, showing similar safety and efficacy than conventional surgery. The objective of this paper is to evaluate the results of an ambulatory surgery program. METHODS: Descriptive retrospective study of the results of the Ambulatory Surgery in a Urology Department, including 4,185 patients in a four-year period, from January 1st 2003 to December 31st 2006. RESULTS: In the study period the global substitution rate was 83.6%. The hospital admission rate was 2.5%, most of which were early admissions. Major complications appeared in 26 patients (0.6%), being major bleeding the predominant one. Most complications were minor or mild, and pain at the site of the surgical wound was the most frequent problem found. CONCLUSIONS: The increase and continuous promotion of ambulatory surgery are more than justified. The high satisfaction among patients undergoing this type of surgery, with a very low number of complications registered, provides us with a valuable tool for health-care expenditure control.

[Current status of the diagnosis and treatment of Leydig cell testicular tumor. Report of two cases]. / Estado actual del diagnóstico y tratamiento del tumor testicular de células de Leydig. Aportación de dos casos.

OBJECTIVES: To review the current diagnosis and treatment of Leydig cell testicular tumors, with special attention to conservative treatment. METHODS: We report two cases of Leydig cell tumor in young adults, diagnosed two years after the appearance of bilateral gynecomastia as first clinical symptom. RESULTS: One year and eight months after orchyectomy, respectively, clinical symptoms completely disappear in the first case and significantly improved in the second. CONCLUSIONS: Around 10% of the cases, and only in adult patients, these tumors may be malignant, being radical orchyectomy the treatment of choice, although conservative surgery may be performed. Independently of the operation, follow-up must be prolonged.

Estado actual del diagnóstico y tratamiento del tumor testicular de células de Leydig. Aportación de dos casos / Current status of the diagnosis and treatment of Leydig cell testicular tumor. Report of two cases

Objetivo: Revisar el diagnóstico y tratamiento actual de los tumores testiculares de células de Leydig, poniendo especial atención en el tratamiento conservador. Métodos: Presentamos dos casos de tumor de células de Leydig en adultos jóvenes, diagnosticados dos años después de aparecer ginecomastia bilateral como primera manifestación clínica. Resultados: al año y ocho meses respectivamente de efectuarse la orquiectomía, las manifestaciones clínicas desaparecieron totalmente en el primer caso y mejoraron ostensiblemente en el segundo. Conclusiones: Alrededor del 10% y sólo en adultos, estos tumores pueden ser malignos, siendo el tratamiento de elección la orquiectomía radical, aunque es posible la realización de cirugía conservadora. El seguimiento de estos pacientes, independientemente de la cirugía practicada, debe ser prolongado (AU)

Objectives: To review the current diagnosis and treatment of Leydig cell testicular tumors, with special attention to conservative treatment. Methods: We report two cases of Leydig cell tumor in young adults, diagnosed two years after the appearance of bilateral gynecomastia as first clinical symptom. Results: One year and eight months after orchyectomy, respectively, clinical symptoms completely disappear in the first case and significantly improved in the second. Conclusions: Around 10% of the cases, and only in adult patients, these tumors may be malignant, being radical orchyectomy the treatment of choice, although conservative surgery may be performed. Independently of the operation, follow-up must be prolonged (AU)

Supervivencia en relación a los factores pronósticos en una serie de pacientes con carcinoma de células renales / Prognostic-factor-related survival in a series of patients with renal cell carcinoma

OBJETIVO: Analizar la supervivencia de una serie de pacientes diagnosticados de carcinoma de células renales durante un periodo de 19 años en base a los factores pronósticos utilizados habitualmente en la práctica clínica. MÉTODOS: Estudio retrospectivo sobre 259 pacientes diagnosticados de manera consecutiva durante los años 1988 a 2006 carcinoma de células renales, que fueron tratados quirúrgicamente en nuestro servicio. A partir de los datos clínicos y patológicos y de seguimiento se ha hecho un estudio de supervivencia comparando el impacto de los factores pronósticos habituales: estadio, tamaño tumoral, grado nuclear, etc. RESULTADOS: Se realizaron 264 cirugías a los 259 pacientes de la muestra que presentaron una edad media de 61,91 años. El diagnóstico se realizó más frecuentemente por hallazgo incidental (52,12% de los casos), practicándose un 72,97% de nefrectomías radicales frente a un 26,25% de parciales. El carcinoma de células claras fue el diagnóstico histológico más frecuente (69,88%). Presentaron peor supervivencia los pacientes con carcinoma de células claras, los tumores sintomáticos, con mayor tamaño y grado nuclear de Fuhrman. A mayor estadio tumoral el pronóstico fue peor, especialmente en los tumores con estadio superior a pT3a. La presencia de ganglios linfáticos afectados o metástasis a distancia presentan una supervivencia cáncer-específica mucho más baja. La de supervivencia cáncer-específica global a los 5 años fue superior al 80%. CONCLUSIÓN: Los factores pronósticos usados clásicamente para predecir la supervivencia del cáncer renal siguen siendo útiles, en especial el estadio patológico pT. Se observa una mejor supervivencia en comparación con series más antiguas, pero este tipo de tumores sigue generando una morbimortalidad importante (AU)

OBJECTIVES: To analyze the survival rate in a series of patients with the diagnosis of renal cell carcinoma over a 19 year period based on prognostic factors usually employed in clinical practice. METHODS: Retrospective study of 259 consecutive patients with the diagnosis of renal cell carcinoma undergoing surgery in our department between 1988 and 2006. From clinical, pathological, and follow-up data we performed a survival study comparing the impact of usual prognostic factors: stage, tumor size, nuclear grade, etc. RESULTS: 264 surgical procedures were performed in 259 patients, with a mean age of 61.91 yr. The most frequent way of diagnosis was incidental finding (52.12% of the cases); radical nephrectomy was performed in 72.97% of the cases in comparison with 26.25% partial nephrectomies. Clear cell carcinoma was the most frequent histological diagnosis (69.88%). Patients with clear cell carcinoma, symptomatic tumors, bigger size, and greater Fuhrman nuclear grade presented worse survivals, mainly in tumors with stage >pT3a. The presence of involved lymph nodes or distant metas- tases is associated with a much lower cancer-specific survival. Global five-year cancer-specific survival was over 80%. CONCLUSIONS: The classical prognostic factors used to predict survival in renal cancer are still useful, mainly pathological stage pT. We observed a better survival in comparison with older series, but this kind of tumors continue generating important morbidity-mortality (AU)

Update on the diagnosis and treatment of bladder endometriosis.

Bladder endometriosis is rare, although the bladder is the urinary tract structure most often affected by this condition. The common clinical manifestations of bladder endometriosis include menouria and urethral and pelvic pain syndrome occurring cyclically. Imaging methods are not conclusive for the definitive diagnosis. Cystoscopy is the most useful diagnostic test with confirmation by histologic study. Treatment must be individualized according to the patient's age, desire for future pregnancies, the severity of the symptoms, the site affected, and whether other organs are involved. Two types of treatment are currently used as follows: medical-hormonal and surgical.

[Prognostic-factor-related survival in a series of patients with renal cell carcinoma]. / Supervivencia en relación a los factores pronósticos en una serie de pacientes con carcinoma de células renales.

OBJECTIVES: To analyze the survival rate in a series of patients with the diagnosis of renal cell carcinoma over a 19 year period based on prognostic factors usually employed in clinical practice. METHODS: Retrospective study of 259 consecutive patients with the diagnosis of renal cell carcinoma undergoing surgery in our department between 1988 and 2006. From clinical, pathological, and follow-up data we performed a survival study comparing the impact of usual prognostic factors: stage, tumor size, nuclear grade, etc. RESULTS: 264 surgical procedures were performed in 259 patients, with a mean age of 6 1.91 yr. The most frequent way of diagnosis was incidental finding (52.12% of the cases); radical nephrectomy was performed in 72.97% of the cases in comparison with 26.25% partial nephrectomies. Clear cell carcinoma was the most frequent histological diagnosis (69.88%). Patients with clear cell carcinoma, symptomatic tumors, bigger size, and greater Fuhrman nuclear grade presented worse survivals, mainly in tumors with stage >pT3a. The presence of involved lymph nodes or distant metastases is associated with a much lower cancer-specific survival. Global five-year cancer-specific survival was over 80%. CONCLUSIONS: The classical prognostic factors used to predict survival in renal cancer are still useful, mainly pathological stage pT. We observed a better survival in comparison with older series, but this kind of tumors continue generating important morbidity-mortality.

[Malignant melanoma of the penis. Report on one case]. / Melanoma mauligno de pene. Aportación de un caso clínico.

OBJECTIVES: Due to the fact that melanoma of the penis is rare, we perform a bibliographic review about the subject and analyze the diagnostic criteria, clinical stages and therapeutic options. METHODS: We report one case that was diagnosed and treated in our department. RESULTS: 85-year-old male who presented with hematuria and a red brownish irregular elevated lesion in the glans penis. Partial penectomy was performed. CONCLUSIONS: Melanoma of the penis is a rare tumoral entity. It accounts for about 1% of all penile malignant pathologies. It has bad prognosis due to fast metastosic dissemination (regional lymph nodes and other organs) and delayed diagnosis. First choice treatment is partial penectomy with or without bilateral inguinal lymphadenectomy (depending upon degree of tumor invasiveness). In cases with metastasis treatment is palliative with chemotherapy and immunotherapy

Melanoma maligno de pene. Aportación de un caso clínico / Malignant melanoma of the penis. Report on one case

OBJETIVOS: Debido a la rareza del melanoma de localización peneana realizamos una revisión bibliográfica sobre el tema y analizamos principalmente cuestiones sobre su diagnóstico, estadiaje clínico y opciones terapéuticas. MÉTODOS: presentamos un caso de melanoma maligno de pene diagnosticado y tratado en nuestro servicio. RESULTADO: se trata varón de 85 años que consultó por hematuria y aparición de una lesión en glande irregular y sobreelevada de color rojo marronáceo. El tratamiento realizado fue penectomía parcial. CONCLUSIONES: el melanoma de pene es una entidad tumoral rara. Supone el 1% de la patología maligna peneana. Tienen un mal pronóstico debido a su pronta diseminación metastásica (ganglionar y a distancia) y porsu frecuente retardo en el diagnóstico. El tratamiento fundamental es la penectomía parcial con o sin linfadenectomía inguinal bilateral (dependiendo del grado de invasión tumoral). En los casos en que existan metástasis a distanciael tratamiento es paliativo con quimioterapia e inmunoterapia

OBJECTIVES: Due to the fact that melanoma of the penis is rare, we perform a bibliographic review about the subject and analyze the diagnostic criteria, clinical stages and therapeutic options. METHODS: We report one case that was diagnosed and treated in our department. RESULTS: 85-year-old male who presented with hematuria and a red brownish irregular elevated lesion in the glans penis. Partial penectomy was performed. CONCLUSIONS: Melanoma of the penis is a rare tumoral entity. It accounts for about 1% of all penile malignant pathologies. It has bad prognosis due to fast metastasic dissemination (regional lymph nodes and other organs) and delayed diagnosis. First choice treatment is partial penectomy with or without bilateral inguinal lymphadenectomy (depending upon degree of tumor invasiveness). In cases with metastasis treatment is palliative with chemotherapy and immunotherapy

Paraganglioma of the bladder: controversy regarding treatment.

Paragangliomas or extra-adrenal pheochromocytomas account for approximately 15% of all pheochromocytomas. They are usually found in an intradiaphragmatic location. Paragangliomas of the urinary bladder are infrequent and represent 6% of the paragangliomas and 0.06% of all bladder tumors. We describe 2 cases of urinary bladder paragangliomas attended to our center and review the literature with special attention to treatment, since there is some controversy around the management of these tumors. Surgical options include partial or total cystectomy and transurethral resection, but there is no consensus regarding these treatment modalities. The 2 patients presented underwent transurethral resection with a good outcome and no recurrence or residual disease.

Tumor epididimario de restos adrenales / Epididymal tumor of adrenal remnants

OBJETIVO: Presentamos el caso de un tumor de tejido suprarrenal ectópico afuncionante, localizado en cola de epidídimo. MÉTODO/RESULTADOS: El caso de un tumor de tejido suprarrenal ectópico afuncionante en adulto y cuya clínica se limitaba al hallazgo casual de una masa testicular izquierda. CONCLUSIÓN: Recordamos que los tumores de dicha estirpe en localización yuxtafuniculogonadal suelen ser benignos aunque la extirpación y estudio histológico están siempre indicados, con el fin de descartar patología metastásica, así como verificar la normalidad del histiotipo (AU)