[Cirugía guiada por la imagen y otros avances en la ayuda al diagnóstico y tratamiento quirúrgico urológico.] / Cirugía guiada por la imagen y otros avances en la ayuda al diagnóstico y tratamiento quirúrgico urológico.

 La evolución de la cirugía va ligada inexorablemente al avance de la tecnología,en un ciclo acelerado que ha transformado completamente el escenario de la cirugía urológica.Poco tiene que ver la realidad actual con la cirugía que los urólogos del siglo XXaprendimos de nuestros maestros...

 La evolución de la cirugía va ligada inexorablemente al avance de la tecnología,en un ciclo acelerado que ha transformado completamente el escenario de la cirugía urológica.Poco tiene que ver la realidad actual con la cirugía que los urólogos del siglo XXaprendimos de nuestros maestros...

Cirugía guiada por la imagen y otros avances en la ayuda al diagnóstico y tratamiento quirúrgico urológico / No disponible

No disponible

Robotic colposacropexy. / Colposacropexia robótica.

OBJECTIVES: To review the role of robot- assisted laparoscopic colposacropexy (RALCS) as a treatment for pelvic organ prolapse (POP) accordingly with the available literature and our own experience. METHODS: We have analyzed the studies with the results of robot-assisted colposacropexy (RALCS) and others in which this technique is compared with the abdominal (ACS) and/or the laparoscopic approach (LCS), including our own series. The main data collected are surgical time, blood loss, complications, clinical outcomes, quality of life and the different costs of LCS versus RALCS. We have reviewed the last systematic reviews and meta-analysis. RESULTS: Clinical outcomes were similar within both RALCS and LCS, surgical time was a bit longer for the robot-assisted compared with laparoscopy, blood loss was similar, as complications. The costs of RALCS were significantly higher than those of LCS, although we must conseconsider that the different studies used different variables to measure them. CONCLUSIONS: Considering that comparative studies are necessary, it is reasonable to assume that RALCS is a feasible and secure technique for the treatment of POP.

Colposacropexia robótica / Robotic colposacropexy

OBJETIVOS: Revisaremos la posición actual de la colposacropexia realizada mediante laparoscopia asistida por robot como manejo de los prolapsos de órganos pélvicos (POP), aportando las distintas evidencias publicadas en las revisiones disponibles en la literatura actual y nuestra propia serie. MÉTODOS: Comparamos según las series disponibles y la propia experiencia de nuestro Servicio la técnica robótica con otros abordajes disponibles en el arsenal terapéutico actual. Se recogen los datos referentes a tiempo quirúrgico, pérdida sanguínea, complicaciones, resultados clínicos, calidad de vida y coste de las dos técnicas en las últimas revisiones sistemáticas y metanálisis publicados. RESULTADOS: Los resultados clínicos de corrección de los POP con ambos abordajes son similares, el tiempo quirúrgico sigue siendo algo mayor con el acceso robótico con una estimación de pérdida de sangre durante el procedimiento similar. La incidencia de complicaciones intra o postoperatorias también es similar en ambas técnicas. El acceso robótico sigue presentando un coste mayor que el laparoscópico. CONCLUSIONES: Aunque se precisan más estudios comparativos con los otros abordajes disponibles, se debe reconocer al abordaje robótico como una técnica factible, reproducible y segura

OBJECTIVES: To review the role of robot-assisted laparoscopic colposacropexy (RALCS) as a treatment for pelvic organ prolapse (POP) accordingly with the available literature and our own experience. METHODS: We have analyzed the studies with the results of robot-assisted colposacropexy (RALCS) and others in which this technique is compared with the abdominal (ACS) and/or the laparoscopic approach (LCS), including our own series. The main data collected are surgical time, blood loss, complications, clinical outcomes, quality of life and the different costs of LCS versus RALCS. We have reviewed the last systematic reviews and meta-analysis. RESULTS: Clinical outcomes were similar within both RALCS and LCS, surgical time was a bit longer for the robot-assisted compared with laparoscopy, blood loss was similar, as complications. The costs of RALCS were significantly higher than those of LCS, although we must consider that the different studies used different variables to measure them. CONCLUSIONS: Considering that comparative studies are necessary, it is reasonable to assume that RALCS is a feasible and secure technique for the treatment of POP

Robotic Anderson-Hynes dismembered pyeloplasty: initial experience.

INTRODUCTION: The introduction of the da Vinci(®) robotic system in 2000 has been a new step forward in the treatment of ureteropelvic junction obstruction (UPJO). The aim of this study was to analyse our initial experience with robot-assisted dismembered Anderson-Hynes pyeloplasty and to perform a bibliographic review on the topic. PATIENTS AND METHODS: We performed 11 robot-assisted pyeloplasties between March 2007 and April 2011. UPJO diagnosis was made on clinical presentation and imaging techniques (CT scan and intravenous urography). All patients underwent basal and diuretic isotopic renograms to evaluate the degree of obstruction and impaired renal function. Median follow-up was 10 (range 1-26) months. RESULTS: Mean patient age was 38.8 (range 23-62) years. There were six women (55%) and five men (45%). All cases were primary surgeries. In four patients the cause of UPJO was a crossing vessel; the other seven patients had intrinsic obstruction. One case was associated with extraction of a calyceal lithiasis. Mean operative time was 189.4 min (125-270 min). Average time from robotic arms docking was 116.5 (range 55-180) min. Average hospital stay was 4.18 (range 2-8) days. Conversion to open or laparoscopic surgery was not necessary in any case and there were no postoperative complications. Postoperative radiological evaluation and renograms showed good results in all cases. CONCLUSIONS: Robotic surgery offers better ergonomics, enhanced three-dimensional (3D) vision and more precise movements, easing intracorporeal suturing.These advantages make robotic pyeloplasty a reproducible technique that combines the high success rates of open surgery and the benefits of laparoscopic surgery.

Prognostic significance of circulating tumor cell count in patients with metastatic hormone-sensitive prostate cancer.

OBJECTIVE: To analyze the correlation between circulating tumor cell (CTC) levels and clinicopathologic parameters (prostate-specific antigen level, Gleason score, and TNM stage) in patients with metastatic hormone-sensitive prostate cancer (PCa) and to establish its prognostic value in overall survival (OS) and progression-free survival (PFS). MATERIALS AND METHODS: A prospective, 3-arm study was performed that included 30 patients with localized PCa; 30 patients with metastatic PCa, and 30 healthy volunteers. A single 7.5-mL peripheral blood sample was taken. The CTCs were isolated using an immunomagnetic method based on the CellSearch system. Kendall's tau and Spearman's rho coefficients of correlation were used. The multivariate Cox regression model addressed OS and PFS. RESULTS: The median follow-up was 42.9 months (interquartile range 27.14-49.5). A significant positive correlation was demonstrated between the CTC level and all tumor burden markers (prostate-specific antigen and T, N, and M stage; P <.001), except for Gleason score (tau = 0.16). A cutoff of ≥ 4 CTCs/7.5 mL was chosen to distinguish patients with a poor prognosis. These patients had a significantly shorter median OS and PFS (24 vs 45 months and 7 vs 44 months, respectively; P <.001). As the CTC level increased, the OS and PFS decreased. The risk of mortality and progression for the patients with ≥ 4 CTCs was 4.1 (P = .029) and 8.5 (P <.001) times greater. Multivariate analyses indicated that a CTC of ≥4 was an independent prognostic factor for PFS (hazard ratio 5.9, P <.005). CONCLUSION: The CTC count in peripheral blood could provide a method of staging PCa correctly and be of value when assessing the prognosis of metastatic hormone-sensitive PCa.

Surgical repair and analysis of penile fracture complications.

BACKGROUND: The objective of this study is to describe and analyze the experience over a period of 10 years at our center through a retrospective study of a series of diagnosed and treated cases of penile fracture. MATERIAL AND METHODS: From 2005 to 2009 the Urology Department of the Hospital Clínico San Carlos of Madrid carried out a retrospective case study of a total of 15 cases of penile fracture. The diagnosis was reached through physical exploration of the patient aided by a penile ultrasound; the immediate treatment performed on the patients was emergency surgical repair. RESULTS: From the total in the series (n = 15), only 1 case was associated with a complete urethral fracture (6.6%). Surgical repair was performed in all cases; the average hospital stay was 2.6 days (range 1-5), and the most frequent long-term complication was erectile dysfunction in 3 of 15 cases (20%). CONCLUSIONS: A penis fracture diagnosis is mostly clinical; complementary tests, such as ultrasound, are helpful but not definitive. Surgical treatment consists of an incision that allows adequate exposure of the corpora cavernosa and urethra to repair the suspected lesions found upon diagnosis. Ambulatory follow-up is essential to diagnose and treat possible complications.

Long-term outcomes after robotic sacrocolpopexy in pelvic organ prolapse: prospective analysis.

OBJECTIVE: To evaluate the feasibility and long-term outcomes of our initial series of robot-assisted laparoscopic sacrocolpopexy. METHODS: We conducted a prospective analysis of our series of robotic sacrocolpopexy. INCLUSION CRITERIA: patients with grades III and IV cystocele and or other symptomatic pelvic organ prolapse. We performed a transperitoneal four-trocar technique with the Da Vinci robotic system using two polypropylene meshes for fixation to the sacral promontory. The primary outcome was recurrence; secondary outcomes included operating room time, blood loss, conversion to open surgery, complications and length of stay. RESULTS: 31 consecutive procedures were included. Mean patient age was 65.2 (50-81) years. Mean operating room time was 186 (150-230) min. We converted 1 case to laparoscopy (3.2%). There were two major complications (1 acute myocardial infarction and 1 reoperation for excess tension with syncopes), two minor complications (1 wound infection and 1 ileus) and no recurrences at a mean follow-up of 24.5 (16-33) months. CONCLUSIONS: Robotic sacrocolpopexy could possibly improve with experience after overcoming the learning curve. There is no doubt it is a reproducible technique, but its safety and efficacy still need to be proven. Our initial series demonstrated good outcomes and no recurrences at 24.5 months of follow-up.

Bladder diverticulum robotic surgery: systematic review of case reports.

INTRODUCTION: We report one case of robot-assisted transperitoneal bladder diverticulectomy and perform a systematic review of published experience. PATIENT AND METHODS: Our patient was a 64-year-old male with a history of lower urinary tract symptoms secondary to benign prostatic enlargement for 6 years with recurrent urinary tract infection. Ultrasound and voiding cystourethrogram showed a 7-cm diverticulum in the posterior bladder wall. After bibliographic search in PubMed/Medline, 17 articles on laparoscopic diverticulectomy and 8 on robotic diverticulectomy were selected. RESULTS: Transperitoneal robot-assisted diverticulectomy was performed with the Da Vinci 4-arm system (Intuitive Surgical Inc., Sunnyvale, Calif., USA) without perioperative complications. Operative time was 80 min and blood loss less than 100 ml. Transurethral prostatic resection combined with Greenlight laser vaporization was performed in a second step. CONCLUSIONS: Robot-assisted bladder diverticulectomy is safe, effective, reproducible and minimally invasive. Cost is higher than for laparoscopic surgery and access to this technology is limited.

Desarrollo multidisciplinario de la cirugía robótica en un hospital universitario de tercer nivel: organización y resultados / Multidisciplinary development of robotic surgery in a University Tertiary Hospital: Organization and outcomes

Introducción El sistema Da Vinci (Intuitive Surgical®) es un telemanipulador quirúrgico que proporciona numerosas ventajas técnicas al abordaje laparoscópico convencional (visión tridimensional, posición ergonómica, precisión en los movimientos, instrumental multiarticular, etc.) y que se viene utilizando en diversas especialidades en todo el mundo desde el año 2000. El primer hospital público español que incorporó esta tecnología robótica fue el Hospital Clínico San Carlos (HCSC) de Madrid en julio de 2006.IntroducciónPresentamos la organización multidisciplinaria y los resultados asistenciales, docentes e investigadores del programa de cirugía robótica (PCR) desarrollado en el HCSC. Material y método Con una dirección común y un equipo común de instrumentistas, se incorporaron progresivamente al PCR los servicios de Cirugía General, Urología y Ginecología, con procedimientos variados y de complejidad creciente. Se programaron numerosas actividades docentes y de difusión tanto intrahospitalarias como extrahospitalarias para dar a conocer el PCR. Resultados Entre julio de 2006 y julio de 2008 se intervinieron 306 pacientes en el ámbito del PCR-HCSC: 169 en Cirugía General, 107 en Urología y 30 en Ginecología. Los resultados demostraron la factibilidad de los procedimientos y su corta curva de aprendizaje. La actividad docente realizada incluyó a residentes y especialistas interesados en la tecnología robótica. Conclusión La incorporación estructurada y gradual de la cirugía robótica mediante el PCR-HCSC ha permitido facilitar el aprendizaje, compartir la infraestructura diseñada, coordinar las actividades de difusión y la colaboración multidisciplinaria. Esta experiencia inicial ha demostrado la eficacia de una organización adecuada y un equipo motivado (AU)

Background Da Vinci system (Intuitive Surgical®) is a surgical telemanipulator providing many technical advantages over conventional laparoscopic approach (3-D vision, ergonomics, highly precise movements, endowrist instrumentation…) and it is currently applied to several specialties throughout the world since 2000. The first Spanish public hospital incorporating this robotic technology was Hospital Clinico San Carlos (HCSC) in Madrid, in July 2006.BackgroundWe present the multidisciplinary organization and clinical, research and training outcomes of the Robotic Surgery Plan developed in the HCSC. Material and methods Starting from joint management and joint scrub nurses team, General and Digestive Surgery, Urology and Gynaecology Departments were progressively incorporated into the Robotic Surgery Plan, with several procedures increasing in complexity. A number of intra and extra-hospital teaching and information activities were planned to report on the Robotic Surgery Plan. Results Between July 2006 and July 2008, 306 patients were operated on: 169 by General Surgery, 107 by Urology and 30 by Gynaecology teams. The outcomes showed feasibility and a short learning curve. The educational plan included residents and staff interested in robotic technology application. Conclusion The structured and gradual incorporation of robotic surgery throughout the PCR-HCSC has made it easier to learn, to share designed infrastructure, to coordinate information activities and multidisciplinary collaboration. This preliminary experience has shown the efficiency of an adequate organization and motivated team (AU)

[Multidisciplinary development of robotic surgery in a University Tertiary Hospital: Organization and outcomes]. / Desarrollo multidisciplinario de la cirugía robótica en un hospital universitario de tercer nivel: organización y resultados.

BACKGROUND: Da Vinci system (Intuitive Surgical) is a surgical telemanipulator providing many technical advantages over conventional laparoscopic approach (3-D vision, ergonomics, highly precise movements, endowrist instrumentation...) and it is currently applied to several specialties throughout the world since 2000. The first Spanish public hospital incorporating this robotic technology was Hospital Clinico San Carlos (HCSC) in Madrid, in July 2006. We present the multidisciplinary organization and clinical, research and training outcomes of the Robotic Surgery Plan developed in the HCSC. MATERIAL AND METHODS: Starting from joint management and joint scrub nurses team, General and Digestive Surgery, Urology and Gynaecology Departments were progressively incorporated into the Robotic Surgery Plan, with several procedures increasing in complexity. A number of intra and extra-hospital teaching and information activities were planned to report on the Robotic Surgery Plan. RESULTS: Between July 2006 and July 2008, 306 patients were operated on: 169 by General Surgery, 107 by Urology and 30 by Gynaecology teams. The outcomes showed feasibility and a short learning curve. The educational plan included residents and staff interested in robotic technology application. CONCLUSION: The structured and gradual incorporation of robotic surgery throughout the PCR-HCSC has made it easier to learn, to share designed infrastructure, to coordinate information activities and multidisciplinary collaboration. This preliminary experience has shown the efficiency of an adequate organization and motivated team.

[Hereditary renal cancer]. / Cáncer de riñón hereditario.

Kidney cancer is the tenth most common cause of cancer death. There are a growing number of genes known to be associated with an increased risk of specific types of kidney cancer. People with Von Hippel-Lindau syndrome have about a 40% risk of developing multiple bilateral clear cell kidney cancers. They can also develop retinal and brain hemangioblastoma, kidneys or pancreas cysts, pheochromocytoma and endolymphatic sac tumor. Four phenotypes with different renal cancer and pheocromocitoma risk have been described depending on the germline mutation. Hereditary papillary renal cell carcinoma syndrome has type 1 papillary renal cell carcinomas associated with protooncogene c-MET germline mutations. Birt-Hogg-Dubé syndrome has FLCN gene mutations associated with fibrofolliculomas, lung cysts with a high risk for spontaneous pneumothorax, and a 15% to 30% risk of kidney cancer (most classified as chromophobe carcinoma, oncocytoma or oncocytic hybrid, but clear cell and papillary kidney cancers have also been reported). Histopathological findings such as oncocytosis and oncocytic hybrids are very unusual outside the syndrome. Hereditary leiomyomatosis and renal cell cancer syndrome shows mutations of Fumarate hydratase gene and cutaneous leiomyomata in 76% of affected individuals, uterine leiomyomata in 100% of females, and unilateral, solitary, and aggressive papillary renal cancer in 10 to 16% of patients. A specific histopathological change is eosinophilic prominent nucleoli with a perinucleolar halo. Tuberous sclerosis complex is one of the most prevalent (1/5.800) hereditary syndromes where renal disease is the second leading cause of death, associated with angiomyolipomas (70%), renal cysts, oncocytomas or clear cell cancer.

Cáncer de riñón hereditario / Hereditary renal cancer

El cáncer de riñón es la décima causa más común de muerte por cáncer. Esta revisión analiza las características de los síndromes hereditarios más frecuentes asociados a un subtipo histológico de tumor renal específico, su prevalencia y penetrancia, test genéticos disponibles y programas de cribado/detección precoz y tratamiento recomendados. En el síndrome de Von Hippel-Lindau un 40% de los pacientes desarrollan carcinoma renal de células claras bilateral y multifocal. También son frecuentes el hemangioblastoma del SNC o retina, feocromocitomas y tumores del saco endolinfático. Se han descrito cuatro fenotipos clásicos de VHL en función de la mutación y un diferente riesgo de feocromocitoma o carcinoma de células renales. Se puede realizar test genético de diagnóstico de confirmación, diagnóstico prenatal o preimplantación. El cáncer papilar renal hereditario tiene múltiples carcinomas papilares bilaterales de subtipo histológico 1. El gen asociado es el proto-oncogen c-met. El síndrome de Birt-Hogg-Dubé por mutaciones en el gen FLCN combina múltiples tumores renales bilaterales de tipo oncocitoma, carcinoma cromófobo, tumor híbrido oncocítico y una minoría carcinoma de células claras renales. Se asocia a fibrofoliculomas cutáneos, quistes de pulmón y neumotórax espontáneo. Histológicamente, hay lesiones iniciales de oncocitosis o híbridos oncocíticos excepcionales fuera del síndrome hereditario. La leiomiomatosis hereditaria y cáncer de células renales por mutaciones del gen fumarato hidratasa tiene en un 15%de los pacientes un agresivo carcinoma papilar tipo 2, en un 75% leiomiomas cutáneos múltiples y en 100% leiomiomas uterinos. En el estudio histopatológico se observan unos macronúcleolos eosinófilos característicos. La Esclerosis tuberosa es uno de los síndromes hereditarios más frecuentes asociado a angiomiolipoma (70% de afectados),quistes renales, oncocitoma o carcinoma renal de células claras (AU)

Kidney cancer is the tenth most common cause of cancer death. There are a growing number of genes known to be associated with an increased risk of specific types of kidney cancer. People with Von Hippel-Lindau syndrome have about a 40% risk of developing multiple bilateral clear cell kidney cancers. They can also develop retinal and brain hemangioblastoma, kidneys or pancreas cysts, pheochromocytoma and endolymphatic sac tumor. Four phenotypes with different renal cancer and pheocromocitoma risk have been described depending on the germline mutation. Hereditary papillary renal cell carcinoma syndrome has type 1 papillary renal cell carcinomas associated with protooncogenec-MET germline mutations. Birt-Hogg-Dubé syndrome has FLCN gene mutations associated with fibrofolliculomas, lung cysts with a high risk for spontaneous pneumothorax, and a 15% to 30% risk of kidney cancer (most classified as chromophobe carcinoma, oncocytoma or oncocytic hybrid, but clear cell and papillary kidney cancers have also been reported). Histopathological findings such as oncocytosis and oncocytic hybrids are very unusual outside the syndrome. Hereditary leiomyomatosis and renal cell cancer syndrome shows mutations of Fumarate hydratase gene and cutaneous leiomyomata in 76% of affected individuals, uterine leiomyomata in 100% of females, and unilateral, solitary, and aggressive papillary renal cancer in 10 to 16% of patients. A specific histopathological change is eosinophilic prominent nucleoli with a perinucleolar halo. Tuberous sclerosis complex is one of the most prevalent (1/5.800) hereditary syndromes where renal disease is the second leading cause of death, associated with angiomyolipomas (70%), renal cysts, oncocytomas or clear cell cancer (AU)

Utilidad del láser en el tratamiento de las estenosis uretrales / The usefulness of laser in the treatment of urethral stenosis

Introducción: La uretrotomía óptica fue introducida por Sachse (lj en 1973 y se ha comprobado una tasa de recurrencia de 75-80% a largo plazo. Esto estimuló la búsqueda de nuevas terapias con una menor incidencia de recurrencia. Se intentaron varios tipos de láser: Nd:YAG, KTP, Argón, Ho:YAG, diodo... Desde finales de los 70 diferentes tipos de láser se han venido utilizando en el tratamiento de las estenosis uretrales. Objetivo: Describir la utilidad de la energía láser en las estenosis uretrales, fundamentalmente recurrentes y analizar la experiencia existente con los diferentes tipos de láser (diodo, Nd:Yag, Holmium, KTP, Argon, etc). Métodos: Hemos realizado una revisión sistemática de la bibliografía, basada en una búsqueda en Medline y análisis detallado de los artículos seleccionados. Conclusiones: 1). El uso del láser en el tratamiento de las estenosis uretrales se revela por el momento como una alternativa válida, eficaz y segura, al menos a medio plazo, a la uretrotomía óptica; sin embargo por el momento no se ha demostrado que sea mejor que esta. 2). La elección del tratamiento es cirujano dependiente, y ninguna técnica ha mostrado claramente ser superior a las demás. 3). Se precisan estudios prospectivos a largo plazo, con un mayor número de pacientes y con mayor seguimiento. 4). La tecnología láser es cara y no está disponible en todos los centros (AU)

Introduction: Optical urethrotomy was introduced by Sachse (1) in 1973 and it has a registered long-term recurrence rate of 75-80%. This stimulated the search for new therapies with less recurrences. Several types of láser were tried: Nd:YAG, KTP, Argon, Ho:YAG, diode,... Since the end of the '70s various types of láser are being used for the treatment of ureteral stenosis. Objectives: To describe the usefulness of the láser energy in the treatment of ureteral stenosis, mainly recurrent stenosis and to analyze the current experience with various types of láser (diode, nd:yag, holmium, argon,...) Methods: We performed the systematic review of the bibliography, based on a medline search, and a detailed analysis of the selected articles. Conclusions: 1) the use of láser in the treatment of urethral stenosis is on the a valid, effective, and safe alternative option to optical urethrotomy, at least in the mid term; nevertheless, it has not demonstrated to date being better than that. 2) The election of treatment is surgeon dependent and, and no single technique has demonstrated to be clearly better than the others. 3) Prospective long-term studies with larger numbers of patients and longer follow-up are necessary . 4) láser technology is extensive and it is not available in all centers (AU)

[The usefulness of laser in the treatment of urethral stenosis]. / Utilidad del láser en el tratamiento de las estenosis uretrales.

INTRODUCTION: Optical urethrotomy was introduced by Sachse in 1973 and it has a registered long-term recurrence rate of 75-80%. This stimulated the search for new therapies with less recurrences. Several types of laser were tried: Nd:YAG, KTP, Argon, Ho:YAG, diode,... Since the end of the '70s various types of laser are being used for the treatment of ureteral stenosis. OBJECTIVES: To describe the usefulness of the laser energy in the treatment of ureteral stenosis, mainly recurrent stenosis and to analyze the current experience with various types of laser (diode, nd:yag, holmium, argon,...) METHODS: We performed the systematic review of the bibliography, based on a medline search, and a detailed analysis of the selected articles. CONCLUSIONS: 1) The use of laser in the treatment of urethral stenosis is on the a valid, effective, and safe alternative option to optical urethrotomy, at least in the mid term; nevertheless, it has not demonstrated to date being better than that. 2) The election of treatment is surgeon dependent and, and no single technique has demonstrated to be clearly better than the others. 3) Prospective long-term studies with larger numbers of patients and longer follow-up are necessary. 4) Laser technology is extensive and it is not available in all centers.

[Robotic assisted laparoscopic colposacropexy in the treatment of pelvic organ prolapse]. / Colposacropexia laparoscópica asistida por robot como tratamiento del prolapso urogenital.

Laparoscopic colposacropexy has become a substitute for open surgery in the treatment of pelvic organ prolapse. In the same way, robotic assisted surgery is a new step in the evolution of the procedure. In this paper we intend to show our surgical technique and preliminary results. From November 2006 to date, 10 patients have undergone this procedure at the Hospital Clinico San Carlos. The main indication for the operation was existence of symptomatic pelvic prolapse. Both patients with or without hysterectomy have been operated, without making significant differences between them. Preoperative evaluation workout included: cystogram, urinary tract ultrasound and urodynamics in all cases; urinary tract MRI was performed only in selected cases. All patients underwent surgery under general anesthesia, with at least three robotic trocars (8 mm) and one conventional trocar for the assistant; 2 accessory trocars were necessary in some cases, mainly at the beginning of the series. Most procedures in our series were associated with a transobturator suburethral sling for the treatment of stress urinary incontinence or prevention of its appearance after prolapse repair. Our results are comparable to those reported in other larger series in terms of operative time, hospital stay and early or late complications. Pending an evaluation on the long term with larger series, we can include robot assisted colposacropexy among the therapeutic options for symptomatic pelvic floor prolapse repair.

Colposacropexia laparoscópica asistida por robot como tratamiento del prolapso urogenital / Robotic assisted laparoscopic colposacropexy in the treatment of pelvic organ prolapse

La colposacropexia laparoscópica es una técnica que ha venido a sustituir a la cirugía abierta para el tratamiento de los prolapsos del suelo pélvico. De la misma manera, la cirugía asistida por robot supone un nuevo paso en la evolución de la técnica. En este artículo pretendemos mostrar, tanto nuestra técnica quirúrgica como los resultados preliminares obtenidos con la misma. En el Hospital Clínico San Carlos han sido intervenidas con esta técnica un total de 10 pacientes, desde Noviembre de 2006 hasta la fecha. La principal indicación en nuestro caso ha sido la presencia de prolapsos pélvicos sintomáticos, habiendose intervenido tanto pacientes histerectomizadas como no histerectomizadas, sin poder establecer diferencias significativas entre ambos casos. Como estudio preoperatorio se ha incluido: Cistografía, Ecografía Reno-vesical, Estudio Urodinámico en todos los casos, y tan sólo en aquellos en los que se ha considerado oportuno una Uro-Resonancia. Todas las pacientes han sido intervenidas bajo anestesia general, mediante colocación de un mínimo de tres trócares robóticos (8mm) y uno convencional para el ayudante, aunque en algunos casos, sobretodo al inicio de la serie se precisaron 2 trócares accesorios. Así mismo, en nuestra serie en la mayoría de los casos se ha asociado una técnica anti-incontinencia tipo sling suburetral transobturatriz, bien para tratamiento de la incontinencia urinaria de esfuerzo (IUE), bien para prevenir su posible aparición tras la correción del prolapso. Los resultados obtenidos son comparables a los descritos en otras series más numerosas en cuanto a duración, estancia hospitalaria y complicaciones tanto precoces como tardías. A expensas de realizar una valoración a largo plazo y con series más amplias, podemos incluir la colposacropexia laparoscópica asistida por robot entre el arsenal terapéutico diseñado para la reparación de los prolapsos del suelo pélvico sintomáticos (AU)

Laparoscopic colposacropexy has become a substitute for open surgery in the treatment of pelvic organ prolapse. In the same way, robotic assisted surgery is a new step in the evolution of the procedure. In this paper we intend to show our surgical technique and preliminary results. From November 2006 to date, 10 patients have undergone this procedure at the Hospital Clínico San Carlos. The main indication for the operation was existence of symptomatic pelvic prolapse. Both patients with or without hysterectomy have been operated, without making significant differences between them. Preoperative evaluation workout included: cystogram, urinary tract ultrasound and urodynamics in all cases; urinary tract MRI was performed only in selected cases. All patients underwent surgery under general anesthesia, with at least three robotic trocars (8 mm) and one conventional trocar for the assistant; 2 accessory trocars were necessary in some cases, mainly at the beginning of the series. Most procedures in our series were associated with a transobturator suburethral sling for the treatment of stress urinary incontinence or prevention of its appearance after prolapse repair. Our results are comparable to those reported in other larger series in terms of operative time, hospital stay and early or late complications. Pending an evaluation on the long term with larger series, we can include robot assisted colposacropexy among the therapeutic options for symptomatic pelvic floor prolapse repair (AU)

[Suburethral readjustable sling (Remeex) for the treatment of female urinary incontinence: personal surgical technique]. / Cabestrillo de tension regulable "Remeex" en el tratamiento de la incontinencia urinaria femenina: tecnica quirúrgica personal.

OBJECTIVES: Currently there is not agreement about the adequate tension for each patient with female stress urinary incontinence treated with urethral slings. The adjustable tension sling Remeex (external mechanic regulation) allows adjustment to ideal tension trying to avoid or minimize possible reoperations. The objective of these paper is to describe the components of the Remeex system, its indications, and the surgical technique to implant and adjust it. INDICATIONS: The Remeex system is indicated for female urinary incontinence in cases of urethral hypermobility, fixed urethra, primary sphincteric dysfunction, failure of other incontinence repaired techniques, and urinary incontinence in bladder hyperreflexia. STUDY PROTOCOL: The diagnosis is made with appropriate history and physical examination and completed with voiding cystourethrogram and urodynamic study, urinary tract ultrasound and, optionally, urethrocystoscopy. Remeex prosthesis characteristics: The system has three elements: polypropylene mesh, pressure tensor, and disconnection tool. TECHNIQUE: 1. Anesthesia: It maybe performed under general or spinal anesthesia. 2. Preparation and patient position. 3. Surgical technique step-by-step:--Abdominal access: 4-6 cm suprapubic incision and development of a supra- aponeurotic space to place the pressure tensor.--Vaginal access: longitudinal incision 1 cm from the urethra meatus, dissection of the vesicovaginal plane, and development of the space to place the polypropylene mesh.--Combined abdominal-vaginal access: bilateral punction with a 20 cm suture-passing needle from the abdomen to the vagina and passage of the mesh from the paraurethral espace threading its sutures in the pressure tensor system, and closure of the incisions.--Cystoscopy.--Tension adjustment and postoperative control. CONCLUSIONS: 1. It is an easy to implant system and a reproducible operation. 2. This technique avoids the morbidity of abdominal operations. 3. It allows the readjustment after surgery through a small suprapubic incision under local anesthesia. 4. Good results have been described in the short and mid-term.

Cabestrillo de tensión regulable "remeex" en el tratamiento de la incontinencia urinaria femenina: técnica quirúrgica personal / No disponible

OBJETIVO: Describir los elementos que componen el sistema Remeex femenino, sus indicaciones y la técnica quirúrgica mediante la que se implanta y ajusta adecuadamente. METODO: Indicaciones: Las indicaciones para la utilización del sistema Remeex en incontinencia urinaria femenina son hipermobilidad uretral, uretra fija, disfunción esfinteriana primaria, fracaso de otras técnicas antiincontinencia, incontinencia urinaria en hiperrreflexia vesical1,2. Protocolo de estudio: El diagnóstico se rea- liza con una adecuada historia y exploración física y se completa con uretrocistografía y estudio urodinámico, ecografía urológica y opcionalmente uretrocistoscopia. Características de la prótesis Remeex: Este sistema esta compuesto por los siguientes elementos: malla de poli- propileno, baritensor, introductor y desacoplador. TECNICA: 1. Anestesia El procedimiento puede realizarse bajo anestesia raquídea o general. 2. Preparación y colocación de la paciente. 3. Técnica quirúrgica paso a paso. 1) Acceso Abdominal. Incisión suprapúbica de 4-6 cm, creación de un lecho supraaponeurotico, para alojar el baritensor. 2) Acceso vaginal. Incisión longitudinal a 1cm del meato uretral, disección del plano vésico-vaginal y creación de un lecho que permita colocar la malla de polipropileno. 3) Acceso combinado abdomino-vaginal. Maniobra de puncion mediante una aguja pasahilos de 20 cm en sentido abdominovaginal (bilateral), paso de los dos extremos de la malla a través del espacio parauretral, enhebrado de los hilos en el sistema baritensor de la prótesis Remeex y cierre de las incisiones vaginales y abdominales. 3. Uretrocistoscopia - Ajuste de tensión y control postoperatorio. CONCLUSIONES: 1. Es una técnica reproducible y el sistema es fácil de implantar. 2. Esta técnica evita la morbilidad de las técnicas abdominales. 3. Permite realizar. 4. Permite reajuste al cabo del tiempo con anestesia local a través de una pequeña incisión suprapúbica. 5. Se han descrito buenos resultados a corto y medio plazo (AU)

OBJECTIVES: Currently, there is not agreement about the adequate tension for each patient with female stress urinary incontinence treated with urethral slings. The adjustable tension sling Remeex (external mechanic regulation) allows adjustment to ideal tension trying to avoid or minimize possible reoperations. The objective of these paper is to describe the components of the Remeex system, its indications, and the surgical technique to implant and adjust it. METHODS: Indications: The Remeex system is indicated for female urinary incontinence in cases of urethral. hypermobility, fixed urethra, primary sphincteric dysfunction, failure of other incontinence repaired techniques, and urinary incontinence in bladder hyperreflexia. Study protocol: The diagnosis is made with appropriate history and physical examination and completed with voiding cystourethrogram and urodynamic study, urinary tract ultrasound and, optionally, urethrocystoscopy. Remeex prosthesis characteristics: The system has three elements: polypropylene mesh, pressure tensor, and disconnection tool. TECHNIQUE: 1. Anesthesia: It maybe performed under general or spinal anesthesia. 2. Preparation and patient position. 3. Surgical technique step-by-step: - Abdominal access: 4-6 cm suprapubic incision and development of a supra- aponeurotic space to place the pressure tensor. - Vaginal access: longitudinal incision 1 cm from the urethra meatus, dissection of the vesicovaginal plane, and development of the space to place the polypropylene mesh. - Combined abdominal-vaginal access: bilateral punction with a 20 cm suture-passing needle from the abdomen to the vagina and passage of the mesh from the paraurethral espace threading its sutures in the pressure tensor system, and closure of the incisions. - Cystoscopy. - Tension adjustment and postoperative control. CONCLUSIONS: 1. It is an easy to implant system and a reproducible operation. 2. This technique avoids the morbidity of abdominal operations. 3. It allows the readjustment after surgery through a small suprapubic incision under local anesthesia. 4. Good results have been described in the short and midterm (AU)

[New male sling "Argus" for the treatment of stress urinary incontinence]. / Nuevo sling masculino "Argus" para el tratamiento de la incontinencia urinaria de esfuerzo.

OBJECTIVES: Male stress urinary incontinence is usually a consequence or sequel of a prostatic surgical procedure (radical prostatectomy, surgery for BPH or bladder neck sclerosis: adenomectomy, conventional and/or bipolar transurethral resection, laser...). This kind of surgery may have undesirable effects on the quality of life and patients' expectations, although we should bear in mind that the primary objective in patients with prostate adenocarcinoma is to cure cancer and for patients with obstructive lower urinary tract symptoms to improve their voiding quality Over the last decade, surgical procedures to compress the bulbar urethra with slings have been employed successfully in the treatment of male stress urinary incontinence, being considered highly effective in the treatment of post-prostatectomy incontinence in the long-term by groups with large experience. To describe the elements of the Argus system, its indications, and the surgical technique for its implant and adjustment, modified from Schäeffer and carried out by Victor Romano. METHODS: Argus system: The sling has three components: radiopaque cushioned system with silicone foam, 42 mm x 26 mm x 9 mm, which is waterproof to body fluids; two silicone columns formed by multiple conical elements, which allow system readjustment; and two radiopaque silicone washers (15 mm diameter and 2.9 mm width) which enable proper fixation and readjustment (Figure 1). Once the system is open, it is recommended to place the sling within antibiotic solution until implantation. CONCLUSIONS: 1. It is a safe, easy to implant, reproducible system, with few complications and a good cost-benefit relation. 2. Results are comparable to the gold standard, but it has the following advantages: immediate voiding control recovery and no need for patient training. 3. This article does not intend to show our short experience with only five cases, but we want to mention that all of them are continent with a good quality of life. 4. Our objective will be to publish our results when we can show a minimal follow-up.