[Proceedings in the implantation of a laparoscopic radical prostatectomy program]. / Implantación de un programa de prostatectomia radical laparoscópica.

OBJECTIVE: To describe our proceedings in the implatation of our laparoscopic radical prostatectomy program (LRP). METHODS: Our working agenda and step-oriented implementation of our LRP program are shown. RESULTS: Four main steps were scheduled to acomplish this goal. These were: Preparatory phase, programed open conversion, development and analysis. Overlapping of each of these phase occured although their major content run on a time-basis. After basic skills acquisition and updating of our equipment we moved into the fixed-time open conversion we allowed us to progresively improve our performance without putting our patients into risks. Operative time of this phase exceeds that of our open cases in 63 minutes and no major complications took place. A rapid decrease in the operative time was noted after the first 15 cases (197' vs 264'). CONCLUSION: Implantation of a program of LRP can be done safely with a pre-planned program tailored to the needs and characteristics of each group and institution.

Implantación de un programa de prostatectomía radical laparoscópica / Proceedings in the implantation of a laparoscopic radical prostatectomy program

Objetivo: Exponer la implantación de nuestro programa de prostatectomía radical laparoscópica (PRL). Material y métodos: Se presenta la metodología y el plan de trabajo seguido en nuestro Centro. Resultados. La implantación del programa de PRL se hace en diferentes de fases coincidentes de manera parcial cronológicamente: fase de preparatoria, fase de reconversión programada, fase de desarrollo y fase de análisis. La primera es un periodo de aprendizaje de la técnica laparoscópica y de adquisición de equipamiento. La fase de reconversión realizada sobre nueve pacientes supone el comienzo de la técnica laparoscópica con una limitación en el tiempo para evitar alargamiento del tiempo quirúrgico y morbilidad. En nuestra experiencia, el incremento medio de tiempo quirúrgico ha sido de 63 minutos respecto a la prostatectomía radical abierta y no hemos tenido complicaciones mayores en este periodo. El tiempo quirúrgico medio disminuyó rápidamente tras los primeros 15 pacientes (197’ vs 264’). Conclusiones: La implantación de un programa de PRL es factible sin que conlleve riesgos añadidos a los pacientes haciéndolo mediante una planificación ordenada previamente que se debe ajustar a las particularidades de cada grupo e institución (AU)

Objective: To describe our proceedings in the implatation of our laparoscopic radical prostatectomy program (LRP). Methods: Our working agenda and step-oriented implementation of our LRP program are shown. Results: Four main steps were scheduled to acomplish this goal. These were: Preparatory phase, programed open conversion, development and analysis. Overlapping of each of these phase occured although their major content run on a time-basis. After basic skills acquisition and updating of our equipment we moved into the fixed-time open conversion we allowed us to progresively improve our performance without putting our patients into risks. Operative time of this phase exceeds that of our open cases in 63 minutes and no major complications took place. A rapid decrease in the operative time was noted after the first 15 cases (197’ vs 264’). Conclusion: Implantation of a program of LRP can be done safely with a pre-planned program tailored to the needs and characteristics of each group and institution (AU)

[Treatment with sildenafil of cold glands syndrome after inflatable penile prosthesis]. / Tratamiento con sildenafilo del síndrome de glande frío tras implante de prótesis hidráulica de pene.

OBJECTIVE: To evaluate the effect of sildenafil on the response of glans penis during sexual intercourse in patients with penile prosthesis who show cold glans syndrome symptoms. MATERIAL AND METHODS: Fourteen patients who had undergone three-piece inflatable penile prosthesis implantation were evaluated. In spite of the normal functioning of the device all of them complained of a degree of dissatisfaction during SI due to a lack of engorgement in the glans penis. The patients were advised to have a dose of 100 mg VO sildenafil about 45 minutes before activating the PP and starting SI. All of them followed this scheme at least three times. They ticked questions 7, 8, 13 and 14 of the International Index of Erectile Function (IIEF) questionnaire with/without having had sildenafil. RESULTS: Twelve out of thirteen patients (85.7%) indicated a more pleasant SI on sildenafil. It was related to an increase in penile glans engorgement and sensitivity. The scores obtained in the IIEF questions showed a significant increase on taking sildenafil. The partners also talked of a more comfortable SI that they related to a less painful penetration. Sildenafil-related morbidity was not found. CONCLUSIONS: Sildenafil could be used to improve functional results of the penile prosthesis in those patients with CGS and seems to increase satisfaction during SI.

Tratamiento con sildenafilo del síndrome de glande frio tras implante de prótesis hidráulica de pene / Treatment with sildenafil of cold glands síndrome after inflatable penile prosthesis

OBJETIVO: Evaluar el efecto de sildenafilo en la respuesta peneana glandular durante la relación sexual (RS) en pacientes con prótesis de pene que muestran síntomas sugerentes de síndrome de glande frío (SGF). MATERIAL Y MÉTODO: Evaluamos catorce pacientes a quienes se había implantado una prótesis de pene (PP) hidráulica de tres piezas. A pesar de un funcionamiento normal del dispositivo, todos los pacientes se quejaban de diversos grados de insatisfacción durante la RS debido a falta de incremento de volumen en glande. Se recomendó a los pacientes la ingestión de una dosis de 100 mg de sildenafilo unos 45 minutos antes de activar la PP e iniciar la RS. Todos ellos siguieron este esquema al menos en tres ocasiones. Respondieron las cuestiones 7, 8, 13 y 14 del Índice Internacional de Función Eréctil (IIEF) con/sin dosis previa de sildenafilo. RESULTADOS: Doce de los catorce pacientes (85,7%) indicaron una RS más placentera tras ingerir sildenafilo. Este hecho fue relacionado especialmente con un incremento en la sensibilidad y volumen del glande. Las puntuaciones obtenidas en las cuestiones del IIEF mostraron un incremento significativo al tomar sildenafilo. Las parejas también referían una RS más confortable que relacionaron con una PV menos dolorosa. No se objetivó morbilidad relacionable con sildenafilo. CONCLUSIONES: Sildenafilo puede ser utilizado para mejorar los resultados funcionales de las PP en pacientes con síndrome de glande frío y parece incrementar la satisfacción durante la RS

OBJECTIVE: To evaluate the effect of sildenafil on the response of glans penis during sexual intercourse in patients with penile prosthesis who show cold glans syndrome symptoms. MATERIAL AND METHODS: Fourteen patients who had undergone three-piece inflatable penile prosthesis implantation were evaluated. In spite of the normal functioning of the device all of them complained of a degreeof dissatisfaction during SI due to a lack of engorgement in the glans penis. The patients were advised to have adose of 100 mg VO sildenafil about 45 minutes before activating the PP and starting SI. All of them followed this scheme at least three times. They ticked questions 7, 8, 13 and 14 of the International Index of Erectile Function (IIEF) questionnaire with/without having had sildenafil. RESULTS: Twelve out of thirteen patients (85,7%) indicated a more pleasant SI on sildenafil. It was related toan increase in penile glans engorgement and sensitivity. The scores obtained in the IIEF questions showed a significant increase on taking sildenafil. The partners also talked of a more comfortable SI that they related to aless painful penetration. Sildenafil-related morbidity was not found. CONCLUSIONS: Sildenafil could be used to improve functional results of the penile prosthesis in those patients with CGS and seems to increase satisfaction during SI

[Echo-guided transrectal biopsy. An analysis of the results in a series of 1900 patients]. / Biopsia transrectal ecodirigida. Análisis de los resultados en una serie de 1900 pacientes.

OBJECTIVE: To compare the results of US-guided transrectal biopsy in 1,900 patients with the diagnostic yield of DRE, transrectal US, PSA, PSA density and free PSA/total PSA ratio and to describe our approach based on the results of the comparative study. METHODS: Over the last two years 1,900 patients have undergone biopsy; 4 to 6 specimens were obtained randomly from both prostatic lobes and areas identified by transrectal US and/or DRE as being suspicious. All patients underwent transrectal US, DRE and determination of serum total PSA and PSA density. Free PSA and free PSA/total PSA ratio were determined in 128 patients with PSA 4-10 ng/ml. Seventy had a second biopsy, 8 a third and 3 had a fourth biopsy. RESULTS: The overall diagnostic yield was 40%. Biopsy was positive in 27% of patients with PSA 4-10 ng/ml; of these, 64% showed a positive DRE, 21% showed a negative DRE and 13% were negative for both DRE and transrectal US. DRE was positive in 32% of patients with PSA greater than 10 ng/ml, 39% of those with PSA 10-20 ng/ml and 62% of those with PSA greater than 20 ng/ml; transrectal US was positive in 58% of patients with PSA 10-20 ng/ml and in 77% of those with PSA greater than 20 ng/ml. A high specificity was found for both DRE and transrectal US. In patients with PSA 4-10 ng/ml, PSA density at a cutoff of 0.15 ng/ml/cc showed a sensitivity of 81% and a specificity of 20%, respectively. A second biopsy was positive in 20% of patients with a persistently elevated PSA and the incidence of tumors theoretically of little importance was 13%. CONCLUSIONS: Patients aged less than 70 years whose general condition permit aggressive treatment of prostate cancer should undergo US-guided transrectal biopsy if PSA is greater than 4 ng/ml, regardless of DRE and ultrasound findings. PSA less than 20 ng/ml, PSA density and free PSA/total PSA ratio must be considered for a second biopsy. Sextant biopsy appears to have a good diagnostic accuracy and does not require taking additional specimens or including the transitional zone in the first biopsy. Before classifying a tumor as being of little importance on the basis of the biopsy findings, another biopsy must be performed.

[Treatment of ureteral obstruction with auto-expandable metallic endoprosthesis]. / Tratamiento de la obstrucción ureteral mediante endoprótesis metálicas autoexpandibles.

OBJECTIVE: To evaluate the efficacy of Nitinol (Memotherm) self-expandible metal stents in the treatment of malignant and non-malignant ureteral obstruction in patients who are not eligible for surgery. METHODS: A total of 14 ureteral strictures (5 malignant, 9 non-malignant) in 13 patients were treated by the implantation of a Nitinol endoprosthesis. Eight were implanted by the antegrade and 6 by the retrograde route. A mean of 1.3 stents were implanted per patient. RESULTS: 85% of the stents were patent at a mean follow-up of 10.2 months (range 2-28). Four prostheses developed transient obstruction that was resolved by insertion of a double-J catheter for periods that ranged from 2 to 6 months. One stent required a permanent double-J catheter and another stent showed functional obstruction, although it was morphologically patent. CONCLUSION: The Nitinol self-expandible metal stent is effective in the treatment of malignant and non-malignant ureteral obstructions in patients who are not eligible for surgery due to the tumor stage or high surgical risk.

[Angioscopy associated with renal transplantation]. / Angioscopia asociada al transplante renal.

OBJECTIVES: To evaluate the usefulness of backtable angioscopy of renal allograft previously to kidney transplantation (KT). METHODS: Twenty five allografts from high risk vascular donors have been angioscopically evaluated. Donors were older than 50 years, with severe aortic atheromatosis, polytraumatized, with cardiac arrest or with vascular lesions or anatomic anomalies of the renal vessels. RESULTS: Forty four per cent (11/25) of the grafts showed vascular pathology on angioscopy: subintimal hematoma (2), intimal tear (2), atheroma plaques (2), venous thrombosis (1) and bench microsurgical vascular reconstruction (4). CONCLUSION: Renal allograft angioscopy is useful in selected cases. It allows to evaluate vascular state of the graft and the quality of microsurgical vascular reconstructions.

[Hybrid tumor of the penis: is this denomination correct?]. / Tumor híbrido de pene: es correcta dicha denominación?

OBJECTIVE: Few cases of verrucous carcinoma of the penis with foci of invasive squamous cell carcinoma have been reported and denominated "hybrid tumors". The accuracy of this term is discussed in this paper. METHODS/RESULTS: A huge penile mass in a patient that had undergone three previous operations for lesions diagnosed as verrucous carcinoma is reported. Partial penectomy was performed. Histological examination showed a very well-differentiated squamous cell carcinoma. PCR (polymerase chain reaction) did not detect any type of human papillomavirus (HPV) in the tumor. CONCLUSIONS: Verrucous carcinoma is a strictly-defined lesion with a different biological behaviour from that of squamous carcinoma. Preoperative deep biopsy may miss the squamous cell carcinoma. Definitive diagnosis can only be achieved by histological examination of the surgical specimen. In future, DNA studies could possibly support preoperative diagnosis of this lesion.

[Neoplasm prevalence in renal transplantation]. / Prevalencia de neoplasias en el trasplante renal.

OBJECTIVE: To analyze the prevalence of neoplasms in renal transplant patients and the relative risk for each tumor type according to the immunosuppression regimen. METHODS: 609 renal transplants were reviewed. The risk index was determined by the ratio of the cases observed and predicted. RESULTS: Tumor prevalence was 4.9% (30/609); 6.3% (25/393) were males and 2.3% (5/216) were females. The most common tumors were cutaneous tumors other than melanoma, accounting for 2.4% (15/609), followed by Kaposi's sarcoma, pulmonary epidermoid carcinoma and genitourinary tumors (0.5%) and non-Hodgkin lymphoma (0.3%). Tumor prevalence was 6.8% for the group treated with azathioprine-prednisone and 3.9% for the cyclosporine A-prednisone-treated group. The estimated relative risk of having a neoplasm was 10-fold higher for the males and 4.2-fold higher for the females vs the general population. The mortality rate was 36.6%; specifically tumor-related in 82%. The mortality rate for those with solid tumors was 77.7%. The long-term survival rate for the group that developed a tumor was significantly lower than that of the general population, 75% vs 53%, respectively (p < 0.05). CONCLUSION: In this series no significant differences were observed relative to tumor prevalence or type according to the immunosuppression regimen. A recipient of a renal graft has a higher risk of developing a tumor. Cutaneous tumors were the most frequent. The long-term survival is lower for recipients of renal grafts who develop a tumor.

[Treatment of arterial stenosis of the kidney graft with transluminal angioplasty]. / Tratamiento de la estenosis arterial del injerto renal mediante angioplastia trasluminal.

OBJECTIVES: The present study was conducted to determine the prevalence of renal artery stenosis (RAS) after kidney transplantation (KT) in hypertensive patients, the efficacy of transluminal angioplasty in the treatment of hypertension secondary to RAS and the morbidity and mortality of angioplasty. METHODS: RAS was suspected in patients with hypertension refractory to medical treatment, with or without functional deterioration or murmur over the graft. Hypertension control, renal function and requirement of drugs were evaluated in 578 transplants performed from 1979 to 1994. RESULTS: The prevalence of hypertension post-transplantation was 43.8% (253/578): 14.2% (42/253) had arteriographically demonstrated RAS, accounting for 7.2% (42/578) of the series. Of these 42 patients, 23 (57%) received antihypertensive drugs: 13 (31%) were treated by angioplasty and 6 (12%) underwent surgical revascularization as the first approach. In the patients submitted to transluminal angioplasty, the stenosis was postanastomotic in 7 and anastomotic in 5: one patient was lost to follow-up. Angioplasty was successful in 8 patients and failed in 4. A graft was lost due to artery thrombosis. Complications were observed in 8 patients. There were no deaths and the incidence of RAS recurrence postangioplasty was 33% (4/12). CONCLUSIONS: RAS is a potentially reversible cause of hypertension post-transplantation. Transluminal angioplasty is the first approach in RAS when medical treatment has failed. The success rate of angioplasty was 66% and the incidence of RAS recurrence was 33%.