Instrumentación transuretral en portadores de esfínter urinario artificial. Presentación y discusión de tres casos clínicos / Transurethral instrumentation in patients with artificial urinary sphincter. Presentation and discussion of three clinical cases

El tratamiento para la incontinencia urinaria masculina de esfuerzo severa es la colocación de un esfínter urinario artificial (EUA). La etiología de la incontinencia con frecuencia es la cirugía prostática previa. Los resultados funcionales son buenos con una tasa aceptable de complicaciones. Las complicaciones son más frecuentes si existe radioterapia previa o se realizan procedimientos transuretrales sin tener en cuenta la presencia del manguito del EUA. Cuando es necesaria la cirugía transuretral, por ejemplo por tumor vesical, es necesario realizar el desabrochado del manguito esfinteriano. Los sondajes uretrales precisan también desactivar el manguito y manipular la uretra con sumo cuidado, evitando su manipulación siempre que sea posible. Se presentan tres casos muy complejos de pacientes portadores de EUA que han precisado diversas soluciones ante manipulación uretral y presencia de complicaciones como estenosis de uretra (AU)

Artificial urinary sphincter (AS) is the gold standard treatment for severe male urinary stress incontinence. The etiology of incontinence is often previous prostate surgery as a radical prostatectomy. Functional results are good with an acceptable rate of complications. If there is prior radiotherapy complications are more frequent. When transurethral surgery, for example for bladder tumor is needed, it is necessary unbuttoned the sleeve. Urethral soundings need also turn off the sleeve and manipulate the urethra carefully, avoiding handling whenever possible. We present three very complex cases of patients with US showing several solutions to urethral manipulation and to resolve complications such as urethral perforation and stricture (AU)

Síndrome de atrapamiento del NP (SANP): revisión del diagnóstico y tratamiento, a partir de un caso clínico / Pudendal nerve entrapment syndrome: review of diagnosis and treatment based on a clinical case

El síndrome de atrapamiento del NP (SANP), es una patología poco frecuente aunque infradiagnosticada. Puede afectar de manera importante la calidad de vida de los pacientes que la padecen. La etiología es por compresión o lesión directa del NP, consecutivos a traumas (deportivos, partos), compresiones por efecto masa o por neuropatías secundarias. El diagnóstico es clínico, basado en el interrogatorio y la exploración física. El tratamiento debe realizarse combinando medidas fisioterapéuticas, farmacológicas y quirúrgicas. Se presenta un caso clínico que ilustra esta patología y la evolución con tratamiento quirúrgico (AU)

Pudendal canal syndrome is a rare but underdiagnosed condition. It can significantly affect the quality of life of patients. The etiology is by direct compression or injury to pudendal nerve, consecutive to trauma (sports, delivery), compressions to mass effect or secondary neuropathies. The diagnosis is clinical, based on the interview and physical examination. Treatment should be done by combining physiotherapy, pharmacological and surgical measures. We present a case report that illustrates this condition and its evolution with surgical treatment (AU)

Complicaciones relacionadas con la colocación de mallas sintéticas en mujeres con incontinencia urinaria y prolapso de órganos pélvicos. A propósito de dos casos / Complications related to the placement of synthetic mesh in women with urinary incontinence and pelvic organs prolapse. A report of two cases

El uso de mallas sintéticas para la corrección de incontinencia de esfuerzo y prolapso de órganos pélvicos requiere de un equipo quirúrgico experto en este tipo de implantes para minimizar las complicaciones y, caso de que estas aparezcan , disponer de los recursos adecuados para solventarlas. Así mismo es importante que las pacientes estén bien informadas sobre la posibilidad de presentar complicaciones asociadas a este tipo de dispositivos. Se presentan dos casos de pacientes de sexo femenino tratadas con mallas sintéticas que presentaron complicaciones asociadas (AU)

Use of synthetic mesh for correction of urinary stress incontinence and pelvic organ prolapse (POP) requires a skilled surgical team in this type of implants to minimize complications and, if these occur, have the resources suitable to solve them. It is also important that patients are well informed about the possibility of developing complications from these devices. They are presented two cases of female patients treated with synthetic mesh that had associated complications. The current literature on this topic is reviewed with a focus on the controversies about the use of mesh and its complications (AU)

Espina bífida y vejiga neurógena. Manejo de un caso complejo con esfínter artificial, ampliación vesical y derivación urinaria / Spina bifida and neurogenic bladder. Managing a complex case with artificial sphincter, bladder augmentation and urinary diversion

Se presenta caso de varón de 26 años con antecedente de espina bífida y mielomeningocele. Diagnosticado de vejiga neurógena con sistema de bajas presiones inicialmente debido a incontinencia de orina fue tratado con esfínter artificial. Después de la operación presentó un patrón de sistema de altas presiones que requirió ampliación vesical, derivación tipo Mitrofanoff y retirada del esfínter. Con ello se consiguió que la presión del detrusor se mantenga dentro de límites seguros durante las fases de llenado y vaciado para proteger la función renal. Es de gran importancia el diagnóstico y seguimiento urológico temprano de los niños y niñas con esta enfermedad mediante los estudios urodinámicos para determinar el patrón vesical y esfinteriano y decidir la mejor estrategia de tratamiento posible. La finalidad fundamental es convertir la vejiga en un sistema de baja presión, conseguir la continencia y preservar la función renal (AU)

Twenty-six years old male with a history of spina bifida and myelomeningocele is presented. Neurogenic bladder with initially low pressure system due to urinary incontinence was treated with artificial sphincter. After the operation presented a pattern of high pressure system that required bladder augmentation, Mitrofanoff diversion and removal of the sphincter. Through these measures safe limits during the phases of filling and emptying of the bladder were achieved, to protect renal function. It is very important the early diagnosis and monitoring of urological children with spina bifida with urodynamic study to determine bladder and sphincter patterns and determine the best possible treatment strategy. The main purpose is to convert the bladder in a low-pressure system, achieve continence and preserve renal function (AU)

Disinergia vesicoesfinteriana lisa. Aportación de un caso clínico y comentarios / Bladder dysinergia. Report of a clinical case and comments

Se presenta un caso en un varón de 40 años con antecedente de colon irritable, que presenta síntomas de vaciado con clínica, con obstrucción infravesical severa en ausencia de compresión prostática, estenosis de uretra y de alteración esfinteriana durante la micción. En las exploraciones se observa un cuello vesical cerrado durante la fase del vaciado, a toda esta clínica se la denomina disinergia lisa o del esfínter liso (obstrucción infravesical funcional). Dentro de las pruebas diagnósticas se resalta el papel del estudio vídeo-urodinámico. La finalidad fundamental en el tratamiento de la disinergia lisa es mejorar el vaciado mediante tratamientos desobstructivos (fármacos y/o quirúrgicos). La videourodinamia ofrece una completa información funcional y anatómica, a tener en cuenta en pacientes jóvenes con obstrucción infravesical (AU)

Male of 40 years with a history of irritable colon, presenting with clinical voiding symptoms, with severe bladder outlet obstruction in the absence of compression prostate, urethral stenosis and sphincter disruption during urination. Bladder neck closed during the emptying phase is observed in the scans, all this clinic is called internal sphincter or smooth dyssynergia (functional bladder neck outlet obstruction). Among the diagnostic tests the role of videourodynamic study is highlighted. The primary purpose in treating this condition is improve obstruction by desobstructive therapies (drugs or surgical). The videourodynamics offers a complete functional and anatomical information to be considered in young patients with bladder outlet obstruction (AU)

Síndrome de dolor vesical: alternativas terapéuticas / Bladder pain syndrome: therapeutic alternatives

El síndrome de vejiga dolorosa (SVD), conocido también como síndrome de dolor pelviano crónico y, de forma clásica, como cistitis intersticial, agrupa una serie de trastornos miccionales con predominio del dolor pelviano o vesical. Una vez establecido el diagnóstico conformularios, cistoscopia, biopsia e hidrodistensión vesical existen una gran variedad de terapias que van desde los tratamientos vía oral, a las instilaciones vesicales con diversas sustancias y, finalmente, la exéresis de la vejiga. Se presenta el caso clínico de una mujer de 46 años diagnosticada de cistitis intersticial, refractaria a tratamientos conservadores, que precisó cistectomía. Se revisan las diferentes alternativas terapéuticas (AU)

Bladder pain syndrome (BPS), also known as chronic pelvic pain syndrome and, conventionally,such as interstitial cystitis, includes a series of voiding disorders predominantly pelvic or bladder pain. When has been diagnosed with cystoscopy, bladder biopsy and hydrodistention, there are a variety of therapies. ranging from oral treatments, to bladder instillations with various substances, and finally the removal of the bladder. We report the case of a 46 year old woman diagnosed intresticial cystitis refractory to conservative treatment, who required cystectomy. Therapeutic alternatives are reviewed (AU)

Esfínter urinario artificial: consideraciones radiológicas sobre sus características morfológicas, ubicación y complicaciones / Artificial urinary sphincter: radiologic considerations about its morphological characteristics, location and complications

La incidencia de incontinencia urinaria en hombres se estima que se encuentra globalmente, en alrededor de un 1-39%. El origen en la mayoría de casos es la realización previa de prostatectomía radical. El EUA es un dispositivo activación manual, cuyo mecanismo impide la pérdida involuntaria de orina y esta indicado en pacientes con incontinencia de esfuerzo moderada a severa con deterioro de la calidad de vida. Las complicaciones pueden ser mecánicas (fallo mecánico, fuga del medio liquido, problemas de llenado del reservorio) y no mecánicas (atrofia o erosión uretral, infección, hematoma, retención aguda de orina, recidiva de la incontinencia, migración). Se realizó una revisión de la literatura, en la que se pretende dar un bosquejo inicial de la valoración del EUA con las diferentes pruebas imagen (AU)

Urinary incontinence in men has a global prevalence of 1-39%. Of those patients, there is a group that develop secondary stress incontinence as an adverse outcome of radical prostatectomy. The artificial urinary sphincter is a mechanical device that allows a urethral occlusion preventing urinary leakage. It is the gold standard treatment for patients that developed stress incontinence after radical prostatectomy. Complications from urinary artificial sphincter are mechanic (mechanical failure, leakage of contrast fluid, problems of reservoir filling) and no mechanic (atrophy or urethral erosion, infection, hematoma, urinary retention, recurrent incontinence, migration). This review show an overview of the artificial urinary sphincter assessment with conventional imaging (AU)

Botox, mucho más que arrugas / Botox, much more tan rides

El primer tratamiento para los pacientes con vejiga inestable son los fármacos anticolinérgicos, que, sin embargo, pueden ser inefectivos o producir efectos adversos. Se han buscado otros tipos de tratamiento como son la neuromodulación o el tratamiento intravesical con toxina botulínica (Botox). Existe una evidencia creciente acerca de la utilidad de la inyección de toxina botulínica en el detrusor para el tratamiento de la hiperactividad vesical. Existen diferentes indicaciones en urología para el Botox aunque no están aceptadas oficialmente: el detrusor hiperactivo neurógeno e idiopático, la disinergia vésico-esfíteriana, cistopatía intersticial y dolor prostático crónico. Presentaremos dos casos clínicos para revisar las diferentes aplicaciones de Botox en urología (AU)

The first treatment for patients with unstable bladder are anticholinergics drugs, however, may be ineffective or cause side effects. Has been sought other types of treatment such as neuromodulation or intravesical treatment with Botulinic Toxine (Botox). There is growing evidence of the usefulness of botulinum toxin injection into the detrusor for the treatment of overactive bladder. There are different indications for Botox in urology but are not officially accepted: neurogenic and idiopathic overactive detrusor, the detrusor-sphincter, interstitial cystitis and chronic prostatic pain. We present two cases to review the various applications of Botox in urology (AU)

Erosión de esfínter artificial. A propósito de un caso / Erosion of artificial sphincter. Report of a case

El esfínter artificial AMS 800® está indicado en casos de incontinencia esfinteriana después de prostatectomía radical (PR). Los pacientes que han sido tratados además con radioterapia externa pueden presentar con más facilidad complicaciones como la erosión uretral. La presentación clínica incluye signos inflamatorios peno-escroto-perineales, retención urinaria o incontinencia y fiebre. Es frecuente que el mecanismo escrotal no pueda activarse debido al edema. El diagnóstico se realiza con uretrocopia y uretrografía. El tratamiento consiste en antibioterapia, colocación de sonda por punción suprapúbica y abordaje quirúrgico urgente, que puede implicar retirada del dispositivo (AU)

The artificial sphincter AMS 800 ® is indicated in cases of incontinence after radical prostatectomy. Patients have been treated with external beam radiation an more easily urethral complications such as urethral erosion. The clinical presentation includes local inflammatory signs, urinary retention or incontinence, and fever: Often, scrotal mechanism cannot be activated due to oedema. Diagnosis is made with urethroscopia and urethroraphy. Treatment consists of antibiotics, placement of suprapubic puncture probe and urgent surgical approach, in our case that involved removal of the device (AU)

Toxina botulínica en el tratamiento de la vejiga hiperactiva idiopática / Botulinic toxin in the treatment of the idiopathic hiperactive bladder

Se presenta un caso clínico de vejiga hiperactiva que ha recibido tratamiento con toxina botulínica (BoNT). La correcta evolución en cuanto a síntomas y la buena tolerancia coinciden con los datos comunicados en la literatura hasta la actualidad. A propósito del caso se realiza una revisión sobre la utilidad de laBoNT en la vejiga hiperactiva

A hyperactive urinary bladder case report of treated with Botulinic Toxin (BoNT) is presented. Good clinica results and tolerance in this case agrees with the previous reported data. As well as we present this case we carry out a review about BoNT usefulness on hyperactive urinary bladder

Tratamiento de la incontinencia urinaria de esfuerzo en el hombre / Treatment of effort bladder incontinence in the male

Actualmente, el tratamiento de elección de la incontinencia urinaria de esfuerzo (IDE) en el hombre es la colocación de un esfínter artificial. Sin embargo, han aparecido otras opciones terapéuticas como las prótesis reajustables con menor coste y menor número de complicaciones que podrían ser usadas, en algunos casos, como tratamiento alternativo. Presentamos el caso clinico de un varón con IDE, tras prostatectomia radical que se trató de forma exitosa con la colocación de un cabestrllo tipo Remeex. Asimismo, se realizó una revisión bibliográflca del sistema Remeex, en cuanto a su colocación, funcionamiento y manejo postoperatorio

Nowadays the gold standard treatment for stress urinary incontinence (SUI) in male is artificial urinary sphincter. New therapeutics options have been developed using a readjustable prosthesis with less cost and less complications, and that could also be used as an alternative treatment. We present a clinical case of a man with SUI after radical prostatectomy, treated successfully with the Remeex system. And we also reviewed the literature of the surgical approach and postoperative management of this system

Bladder blood flow and de-obstructive open prostatectomy: correlation with clinical and urodynamic parameters.

PURPOSE: To assess the relation between tissue blood flow changes during surgery with clinical and urodynamic parameters in obstructed patients. MATERIAL AND METHODS: A prospective study was conducted in 18 symptomatic patients with bladder outlet obstruction undergoing retropubic prostatectomy. A symptom assessment and a preoperative urodynamic study were performed. To measure bladder blood flow a BLF-10 laser Doppler flowmeter and a blunt-tipped probe were used intraoperatively. Tissue flow was measured in TPU units (1 TPU unit=1 ml per minute per 100 mg of tissue). Six measurements were taken: two control in the rectus abdominis muscle and four in the detrusor, two before the incision of the prostatic capsule and two after closure. For the statistical analysis, Wilcoxon test and a regression analysis were performed. RESULTS: Mean age was 70 years (range: 56-84). Six patients had an episode of acute urinary retention (AUR). No differences were found in the initial and final values of bladder blood flow of the rectus muscle and the bladder dome. A decrease of bladder blood flow in the anterior bladder wall was observed after prostate enucleation. AUR patients showed no differences in bladder blood flow values. Bladder blood flow (BBF) changes showed no correlation with any urodynamic or clinical parameter. CONCLUSIONS: Laser Doppler flowmetry is useful to study BBF with low morbidity, ease of use and reproducibility. Following de-obstructive surgery, a decrease in BBF occurs, probably associated with surgery. These changes are similar in patients with and without AUR and show no correlation with other parameters studied.

Solifenacin appears effective and well tolerated in patients with symptomatic idiopathic detrusor overactivity in a placebo- and tolterodine-controlled phase 2 dose-finding study.

OBJECTIVES: To evaluate the dose-response relationship and safety/tolerability of solifenacin succinate (YM905) in the treatment of overactive bladder (OAB), and to compare its efficacy and safety/tolerability with tolterodine 2 mg twice daily. PATIENTS AND METHODS: This multicentre study included a 2-week single-blind placebo run-in, a 4-week double-blind placebo-controlled active treatment phase, and a 2-week follow-up. Men and women with an OAB and urodynamic evidence of detrusor overactivity were randomized to placebo or solifenacin 2.5, 5, 10 or 20 mg once daily, or tolterodine 2 mg twice daily. RESULTS: Of 265 patients enrolled, 225 were randomized and 192 completed the study. Solifenacin 5, 10 and 20 mg produced statistically significant (P < 0.05) improvements in voids/24 h vs placebo, whereas tolterodine did not; the mean change with tolterodine was between those with solifenacin 2.5 and 5 mg. The outcome was similar for the mean change from baseline to endpoint in mean volume voided/void. For incontinence and urgency episodes/24 h the solifenacin dose groups showed numerically superior changes vs placebo; the mean effects with tolterodine were generally smaller than with solifenacin. Most of the efficacy effect of solifenacin was evident at 2 weeks. Quality-of-life outcomes supported the efficacy results. Solifenacin 5 and 10 mg were well tolerated; there were no serious treatment-related adverse events. The incidence of dry mouth was 14% for solifenacin 5 and 10 mg, 2.6% for placebo and 24% for tolterodine. CONCLUSION: In this study, the 5- and 10-mg doses of solifenacin appeared to be the most clinically effective for treating OAB, considering the balance between efficacy, quality of life and tolerability. From the results of this study solifenacin 5 and 10 mg were selected for further evaluation in large-scale phase 3 studies.

Abordaje transobturatriz en er tratamiento de la incontinencia de esfuerzo / Transobturator treatment of the stress urinary incontinence

A partir de un caso clínico, se explica una nueva técnica quirúrgica, que se está utilizando en la actualidad, para el tratamiento de la incontinencia de orina de esfuerzo (IOE) (AU)

Tratamiento de la incontinencia urinaria de esfuerzo con el sistema REMEEX / Treatment of stress urinary incontinence with the system REMEEX

Presentación de los métodos diagnósticos de la incontinencia urinaria de esfuerzo, de ausa intrínseca, con especial referencia al sistema de sling de tensión regulable (AU)

Urodynamic evaluation and management prior to renal transplantation.

OBJECTIVES: To evaluate the indications for urodynamics studies (UDS) previous to renal transplantation (RT) and the results of bladder cycling (BC), performed in selected cases. METHODS: Among 475 RT, 33 patients (6.9%) required UDS according our protocol. Indications were: (1) low urinary tract symptoms (LUTS); (2) defunctionalized bladder (DB), and (3) complex urologic history (reflux, neurogenic bladder, urethral valves, etc.). DB was defined as a total urinary output of <300 ml/24 h. Patients with DB underwent BC through a suprapubic catheter, undergoing UDS after BC. The rate and type of urodynamic anomalies were compared among the 3 groups. Cystometric capacity (CysCap) and compliance were evaluated according to the etiology of renal failure, diuresis, and number of previous bladder surgeries. RESULTS: Fifteen patients (45%) showed abnormal UDS, Increased pressure at cystometry was the most frequent finding (46%). The rate of abnormal UDS among the 3 groups was not statistically significant (66.6% in DB, 42.8% in LUTS, and 35% in those with complex urologic history). Compliance and CysCap were significantly lower in the patients with DB, showing a significant correlation with diuresis. These parameters did not correlate with the number of previous bladder surgeries. BC resulted in normal UDS in 3 patients (33%) and a change in diagnosis in 2 patients (22%). CONCLUSION: Our indications gave a good diagnostic yield. Patients with DB represent a group with different urodynamic findings. BC provides a more precise diagnosis or normalization of UDS in some cases.

Clear cell adenocarcinoma in a female urethral diverticulum.

The incidence of a neoplasm within the female urethral diverticulum is rare. Clear cell adenocarcinoma, which is the most common neoplasm, arises from the metaplasia of surface transitional epithelium and the paraurethral ducts. These tumors are usually diagnosed at a late stage, which worsens their prognosis. The treatment of choice is surgery.

The reliability of cysto-urethrographic signs in the diagnosis of detrusor instability in children.

OBJECTIVE: To assess whether the signs associated with detrusor instability (DI), as assessed by video-urodynamic studies, can be evaluated by conventional voiding cysto-urethrography (VCUG). PATIENTS AND METHODS: Fifty-nine children who underwent cystometry and VCUG were reviewed and divided into two groups; group 1 comprised 51 neurologically normal children who had DI (47 girls and four boys, mean age 7.9 years, range 4-14), with no malformations or previous surgery. Most had mixed symptoms, including urinary tract infections (44) and nocturnal enuresis with daytime symptoms (20); group 2 (control) comprised eight children (seven girls, mean age 9.7 years, range 6-15) with a stable bladder and the same clinical presentation. The interval between VCUG and cystometry ranged from 1 day to 5 months (mean 47 days) and was similar in both groups. Signs considered suspicious of DI were sought in the findings of VCUG. RESULTS: In group 1, VCUG was normal or showed no specific signs (only vesico-ureteric reflux or vaginal voiding) in 25 (49%) of patients, whereas 26 (51%) had some signs suspicious of DI. Suspicious signs were urethral ballooning (in 11), bladder trabeculation or a constricting ring (eight), a 'spinning-top' urethra (three), urethral notching (two) and Mercier's bar (one). In group 2, five patients had no abnormal findings on VCUG and three had suspicious signs. The positive predictive value of VCUG was high (0.89) but the diagnostic yield of suspicious signs was low, because the sensitivity (0.5), specificity (0.62) and overall accuracy (0.52) were low. CONCLUSION: Radiological signs suspicious of DI cannot be regarded as such in conventional VCUG, as although they were detected in half the patients with DI, they also occurred in three of eight children with a stable bladder.