[Evolution of the clinical presentation of renal cancer. Fifteen years experience]. / Evolución de las manifestaciones clínicas del cáncer renal. Experiencia de 15 años.

OBJECTIVE: To evaluate the evolution of the clinical presentation of this malignancy over time, and its possible prognostic repercussions. METHODS: A retrospective study of 538 patients subjected to surgery due to renal cancer in our hospital during the period 1995-2011. An analysis was made of the evolution of the clinical manifestations at the time of diagnosis, stratifying the results by years during four time periods. RESULTS: At the time of diagnosis, 53,4% of the patients were asymptomatic for 1995-1999 and 72% in the period 2008-2011. Pain is the symptom that occurs most frequently (18.8%) followed by hematuria (15.4% ). The proportion of symptomatic patients increases in relation to stage and histopathological grade. CONCLUSIONS: The clinical presentation of renal cancer has evolved over the years, not in terms of symptoms, which when present are still similar, but in terms of their incidence.

Simultaneous Cystectomy and Nephroureterectomy due to Synchronous Upper Urinary Tract Tumors and Invasive Bladder Cancer: Open and Laparoscopic Approaches.

INTRODUCTION: It is not unusual for bladder tumors to appear following transitional cell carcinoma of the upper urinary tract (UUT), with involvement of the UUT, following invasive bladder cancer, being less common. The synchronous presence of transitional cell carcinoma of the bladder and of the UTT is exceptional. METHODS: Fifteen simultaneous cystectomies with nephroureterectomies were performed due to synchronous UUT and invasive bladder cancers (1997-2009). Surgery was performed using an open approach in 10 patients, while the last 5 procedures were performed laparoscopically. RESULTS: The mean age was 68.7 years. Mean surgery time was 348.6 minutes. Mean blood loss was 816 ml. Acute renal failure was the most frequent postoperative complication being present in 5 patients (33%). There was 1 case of a leak in the ureter-intestinal anastomosis (open approach), which required placement of a left-sided percutaneous nephrostomy. There were 2 cases of postoperative mortality, both in the open approach series and with intestinal neobladder. Mean follow-up time for the whole series was 21.25 months. Eight cases experienced metastatic progression of the disease (mean follow-up 17 months). CONCLUSION: Though multi-site studies with longer follow-up and a greater numbers of patients are needed, the moment at which urothelial tumors appear seems to influence their prognosis, with lower survival rates for tumors that synchronically appear.

Flexible ureterorenoscopy (URS): technique and results.

OBJECTIVES: This paper has two main objectives: First, to expose the URS technique used in our Department because there are important differences with respect to others centres published, explaining same aspect that can benefit to the better development of the technique. Second, we present the results of a series of 100 cases. Flexible ureterorenoscopy (Flex URS) has been little used to date, mainly because of the technical difficulties created by the deficient quality of the instruments used, such as ureteroscopes offering scant visibility, poor illumination, a small working channel, deficient quality of the forceps and baskets, etc. METHODS: We present our recent series of flexible URS for the treatment of renal lithiasis. We performes a retrospective analysis of this treatment corresponding to the period between January 2007 and March 2010. In this period we have treated 100 patients. The medium size of the stone treated is 1.5cm (0.5-6cm) and we used ureteroscopic protector sheath in all cases. The lithotripter system used in all cases was Ho:YAG Laser with 200 and 365 micras fibers RESULTS: The stone-free rate (SFR) in the immediate postoperative period was 77% (77/100 patients). Residual stones, defined as stone fragments visualized in the operating room via fluoroscopy and directly with the flexible ureteroscope. Three months after surgery, the SFR was 92.7% (89/96 patients) confirmed by intravenous urography. Regarding complications, we had 5 patients with ureteral lesions during protector sheath pass and 9 patients that presented at the emergency room with pain secondary to the double J catheter. CONCLUSIONS: Flexible URS for of renal lithiasis can be defended in stones measuring up to 2 cm in diameter, based on our treatment algorithm.

Laparoscopic transperitoneal radical prostatectomy in renal transplant recipients: a review of the literature.

OBJECTIVES: To report our experience with laparoscopic radical prostatectomy (LRP) for the treatment of localized prostate carcinoma in two renal transplant recipients and a review of the literature. PATIENTS AND METHODS: We retrospectively identified all patients who had undergone LRP for clinically localized prostate cancer between 2002 and 2008 at our institution (n = 1150). Of these patients, two were renal transplant recipients (one with donor renal transplant cadaver and the other with prior transplantectomy). We reviewed all available clinicopathological data and the scientific literature. RESULTS: The two patients underwent successful LRP with no major complications. The mean (range) operative time was 200 (180-220) min with a mean estimated blood loss of 300 (200-400) mL. There were no changes in renal graft function as measured by serum creatinine level. At pathology, the surgical margins were negative and disease was organ-confined in each case. The two patients tolerated the procedure well and had a mean (range) hospital stay of 3.5 (3-4) days. CONCLUSIONS: The data from our two patients suggest that LRP, as an accepted minimally invasive treatment for a middle-aged man with organ-confined prostate cancer, is a technically feasible and safe treatment of localized prostate cancer in renal transplant recipients.

[Prostatic specific antigen (PS), pro-inflammatory cytokines, and prostatic pathology (benign prostatic hyperplasia and cancer). Relationship with malignancy]. / Antígeno prostático-específico, citoquinas pro-inflamatorias y patología prostática (hiperplasia benigna y cáncer). Relación con la malignidad.

OBJECTIVES: Cancer is a complex process in which cytokines play an important role. Cytokines are low-molecular weight soluble proteins involved in cellular transmission signals and several disorders. Pro-inflammatory cytokines (IL-1, TNF-alpha and IL-6) are involved in prostate cancer development. The aim of this study was to relate the expression (analyzed by Western blot and immuno-histochemistry) of several pro-inflammatory cytokines (IL-1, TNF-alpha and IL-6) with serum levels of prostate-specific antigen (PSA) in normal (no pathological samples) as pathological samples (hyperplasia and cancer), in order to elucidate their possible role in tumor progression. We are also discussing the possible use of these cytokines as a potential therapeutic target. METHODS: This study was carried out in 5 normal, 25 benign prostatic hyperplastic (BPH) and 17 prostate cancer (PC) human prostates. Immunohistochemical and Western blot analysis were performed. Serum levels of PSA were assayed by a PSA DPC immulite assays (Diagnostics Products Corporation, Los Angeles, CA). RESULTS: In BPH, IL-1alpha, IL-6 and TNF-alpha were only expressed in patients with PSA serum levels of 0-4 ng/ml or 4-20 ng/ml, but not in the group >20 ng/ml. In PC these cytokines were only expressed in patients with PSA serum levels >4 ng/ml, although the expression of these cytokines was elevated when PSA levels were >20 ng/ml. CONCLUSIONS: In PC there might be an association between high expression of pro-inflammatory cytokines (IL-1, TNFalpha and IL-6), elevated serum levels of PSA and cancer progression. A better understanding of the biologic mechanism of this association may improve the finding of new targets for therapy in these patients.

[Laparoscopic radical nephrectomy in big surgical specimens]. / Nefrectomía radical laparoscópica en piezas quirúrgicas de gran tamaño.

INTRODUCTION: The retroperitoneal surgery is the clearer indication for the laparoscopic approach. Still there are indications for open surgery because of the complexity of the patient and the surgeon experience. OBJECTIVES: The main objective is to report our experience of laparoscopic radical nephrectomies in patient with tumors greater than 7 cm. or surgical specimens with more than 700 g of weight. We analyze their characteristics, complications rate, surgical time, postoperative outcome and hospital stay. MATERIALS AND METHODS: Since July 2004 to July 2008 we have performed 104 laparoscopic radical nephrectomies. We have selected 41 patients with characteristics of big surgical specimens. RESULTS: The average surgical time has been of 184,3 min. Only 1 case has been converted into open surgery and only 1 intraoperative death because of cardiologic arrhythmia. The average hospital stay has been of 3,51 days. The complications rate and postoperative outcome are similar to the whole series. DISCUSSION: Laparoscopic nephrectomy is technically less complex than radical prostatectomy. However, their possible complication implies a much bigger severity. The more complex cases must be approach laparoscopically only after a wide experience. Actually, in our department we usually indicate an open approach when surgical specimen crossover the abdominal middle line and in those cases where the tumoral thrombus affect the main renal vein and/or the vena cava.

[Laparoscopic radical nephrectomy. Procedure, results, and complications]. / Nefrectomía radical laparoscópica. Técnica, resultados y complicaciones.

Surgery is the treatment of choice for clear cell renal carcinoma not responding to chemotherapy, radiotherapy, or immunotherapy. The surgical procedure used has evolved over time in the past 40 years, mainly because of the development and widespread use of diagnostic procedures such as ultrasonography and CT. As a direct consequence, parenchymal-sparing surgery was no longer only used for patients with solitary kidneys and its indication started to be extended to patients with tumors up to 4 cm in diameter, in whom it has been shown to be a safe and effective alternative to radical nephrectomy. The other important milestone in development of renal cancer surgery undoubtedly was the revolution started in the 90s with advent of laparoscopic renal surgery, which has become established over the past 20 years approximately. Laparoscopic surgery initially raised concern about oncological safety, but clinical series with sufficiently long follow-up times and large sample sizes are now available to consider the laparoscopic approach as a reliable procedure. Technological development has caused the laparoscopic technique to be no longer seen as a procedure for the future, but rather as an absolutely current technique which should be implemented in most urology departments. Implementation of any new procedure usually involves a number of complications which we should be prepared to assume, while making every effort to try and prevent them. It is therefore essential to develop, and to implement using common sense, a training program on the procedure. Selection of patients and conditions to be treated is a crucial part of such a program.

[Renal live donor. Open and laparoscopic experience at La Paz Hospital]. / Donante vivo renal. Experiencia de cirugía abierta y laparoscópica. Hospital La Paz.

UNLABELLED: Laparoscopic live donor nephrectomy is a rare operation in our country because the complexity of the technique and the expansion of the cadaveric donor. We present our open and laparoscopic live donor nephrectomy from 1984. MATERIAL AND METHODS: From 1984 to 2007 we have done 84 live donor nephrectomies; 64 open, 20 laparoscopic surgeries. The transperitoneal approach is preferred in laparoscopy and lumbotomy for the open surgery. RESULTS: In the open technique the operating time is 112 min (70-155), ischaemia time 20 seconds (15-47) and postoperative hospital stay 4,8 days (3-9). Laparoscopic cases, the operating time is 146 min (90-210), ischaemia time 3 min 15 sec (2-3, 25 min) and postoperative hospital stay 3,4 days (2-9). CONCLUSIONS: The laparoscopic live donor nephrectomy is a difficult and demanding technique. It should be done by experienced team in laparoscopic renal surgery. The kidney from a live donor is a very good alternative for the cronic renal failure. It should be offered in our main hospitals.

Urinary tract endometriosis: clinical, diagnostic, and therapeutic aspects.

OBJECTIVES: To describe our experience at La Paz University Hospital with 12 patients with urinary tract endometriosis, an uncommon pathologic finding, the most extensive series published by Spanish investigators to our knowledge. METHODS: We performed a retrospective analysis of 12 cases of urinary tract endometriosis diagnosed from 1993 to 2008. RESULTS: The mean patient age was 37.75 years. Of the 12 patients, 5 had bladder involvement and 7 had ureteral involvement, 2 bilateral, 2 left, and 3 right. In those with bladder endometriosis, the diagnosis was made by cystoscopy and biopsy in 4 patients. Treatment consisted of laparoscopic hysterectomy and partial cystectomy in 1 patient and exploratory laparotomy, transvesical resection, and transurethral resection of the bladder in 3 patients. One of the patients who underwent transurethral resection of the bladder experienced 2 relapses. The first relapse was treated with transurethral resection of the bladder and the second with laparoscopic partial cystectomy. In the patients with ureteral endometriosis, the diagnosis was mainly established by magnetic resonance imaging. Treatment consisted of ureteroneocystostomy in 5 patients (bilateral in 1) and laparoscopic ureterolysis in 2, with later ureteral resection and end-to-end anastomosis in 1 of them. The patient who underwent bilateral ureteroneocystostomy finally required right autotransplantation because of early ureteral relapses. CONCLUSIONS: Urinary tract endometriosis is an uncommon pathologic finding. Surgery is the treatment of choice. We believe partial cystectomy should be considered as an initial option in selected cases, depending on the extent and location of lesions. For cases of ureteral endometriosis, the initial technique depends on the location and depth of the lesion.

[Pheochromocytoma: laparoscopic treatment]. / Feocromocitoma: tratamiento laparoscópico.

OBJECTIVE: We report this clinical case not only for the laparoscopic approach of a pheochromocytoma but also because of its particular aggressiveness and oddity of its clinical presentation. METHODS: 44 years old male presenting with oppressive chest pain with accompanying vegetative symptoms, who was diagnosed of right adrenal pheochromocytoma. RESULTS: After the diagnosis of pheochromocytoma was established and double adrenergic blockage implemented, transperitoneal laparoscopic surgery was performed. Pathological analysis of the surgical specimen confirmed the clinical diagnosis of pheochromocytoma. Patient was discharged home two days after surgery without any complication. CONCLUSIONS: The laparoscopic approach of adrenal pheochromocytoma is possible and safe in centres with laparoscopic experience, obtaining the same results than open surgery, offering advantages for the patient such as less pain, smaller incisions, and early ambulation, which results in a shorter hospital stay.

[Bladder neurofibroma: case report and bibliographic review]. / Neurofibroma de la vejiga: caso clínico y revisión de la literatura.

OBJECTIVE: The prevalence of the disease is 1/3000 newborns; it is more frequent in men than in women with a 3:1 ratio in all races. Genitourinary tract neurofibromas usually arise from the pelvic and bladder nerves, and the prostatic plexus. Bladder is the most frequently affected organ of the urinary tract; bladder neurofibromatosis may present as a diffuse infiltrative process or an isolated neurofibroma. Bladder neurofibromas arise from nervous ganglia of the bladder wall and stain positive for protein S-100 and type IV collagen with immunohistochemical techniques. METHODS: We performed a bibliographic review about urinary tract neurofibromas, and specifically of bladder neurofibroma. We report the case of a 45-year-old female consulting for voiding symptoms and recurrent urinary tract infections. Imaging tests showed a mass in the left lateral wall of the bladder and diffuse thickening of the bladder wall. The thickening of the bladder wall is the most characteristic finding in imaging tests, which may also be present in other diseases such as inflammatory pseudotumor and leiomyoma, so that final diagnosis should be achieved by pathologic study. RESULTS: The case is relevant for the absence of previous diagnosis of neurofibromatosis, being bladder involvement its clinical debut. This is why it was difficult to suspect the final diagnosis: the absence of other characteristic clinical manifestations of the disease. Transurethral resection of the tumor was performed and pathologic and immunohistochemical studies offered the final diagnosis. The patient was followed in the urology clinic and also sent to the internal medicine department to rule out other organs involvement of the disease. CONCLUSIONS: Neurofibromatosis is a rare systemic disease, and urinary tract involvement is rarer. Bladder is the most frequently involved organ in the urinary tract, generally as a diffuse infiltration or more rarely a solitary tumor. The final diagnosis is pathological and immunohistochemical. Treatment is usually conservative. The patient should be worked up to rule out other manifestations of the disease, and followed to evaluate the development of new lesions.

[Erectile dysfunction after radial prostatectomy. Response to treatment with sildenafil citrate]. / Disfunción eréctil postprostatectomía radical. Respuesta al tratamiento con citrato de sildenafilo.

OBJECTIVES: Erectile dysfunction is one of the sequelae after radical prostatectomy most concerning for the patient, its appearance being influenced by factors such as surgical technique, or patient's age. Thus, around 40% of the patients younger than 70 years and over 90% of the patients older than 70 present with erectile dysfunction after prostatectomy. We studied the response to sildenafil citrate in patients who underwent non nerve sparing radical prostatectomy. METHODS: Medical records of 100 patients who underwent radical prostatectomy at our department between 1985 and 1998 were retrospectively reviewed and telephone interviews were done to investigate the degree of erectile dysfunction following surgery. All patients were offered to start a two-month therapeutic trial with sildenafil citrate, in dose escalation up to a maximum of 100 mg. Therapeutic response was evaluated by personal interviews. RESULTS: 5 out of 100 patients interviewed showed similar potency than preoperatively. Among 95 patients with erectile dysfunction 63 (66.3%) did not wish treatment for erectile dysfunction. 22 of the remainder 32 patients initiated treatment with sildenafil citrate, whereas 10 preferred trying intracavernous PGE1 injections only. In the intracavernous injections group 5 patients abandoned because of pain with injections and refused any further treatment with oral drugs; 5 patients are satisfied with intracavernous therapy and they do not want to try sildenafil. In the sildenafil group form 22 patients starting treatment 14 (63.6%) are satisfied, with a subjective improvement. Only 5 patients (22%) show an erectile response enough to have sexual intercourse with penetration. 8 (36.5%) abandon treatment because of lack of efficiency. CONCLUSIONS: 5% of the patients who undergo non nerve sparing radical prostatectomy maintain sexual potency without treatment postoperatively. Most patients with postoperative erectile dysfunction (63/95 = 66.3%) do not want any treatment. From 22 patients initiating treatment with sildenafil 5 can have sexual intercourse with penetration (5/22 = 22%), all of them with 100 mg doses of sildenafil.

[Mesothelial cysts in urology: a diagnostic and therapeutic problem]. / Quistes mesoteliales en urología; un problema diagnóstico y terapéutico.

OBJECTIVE: To present our experience with mesothelial cysts with excretory system involvement. METHODS: 3 cases of mesothelial cyst are presented; two of them caused obstructive uropathy. RESULTS: Cases 1 and 2 were treated by surgery, while case 3 was managed conservatively. All cases are currently asymptomatic. CONCLUSIONS: Mesothelial cysts are an uncommon cause of obstructive uropathy. Treatment is by surgery for the symptomatic cases and conservative management is a valid alternative for the asymptomatic cases.