[Complications and incidences in our first 250 robotic radical prostatectomies]. / Incidencias y complicaciones en nuestras primeras 250 prostatéctomias radicales robóticas.

OBJECTIVE: To review the incidence of and analyze the factors contributing to perioperative complications in patients undergoing robotic radical prostatectomy in our experience of 250 procedures. MATERIALS AND METHODS: An analytical, descriptive, retrospective study was conducted of 250 consecutive patients who underwent robotic radical prostatectomy during a period of three years and two months (January 06-March 09). Data recorded included age, preoperative Gleason grade and PSA, and prostate volume. All procedures were performed by three surgeons through a transperitoneal approach using a four-arm da Vinci robotic system. Microsoft Excel support was used. Surgical variables recorded included setup time, console operation time, mean bleeding, transfusion rate, hospital stay, and urethral catheterization time. Incidences and intraoperative and postoperative late and early complications in these patients were reviewed. RESULTS: Demographic data recorded included: mean age, 61.5 years (47-74); mean preoperative PSA, 8.18 ng/mL (2.6-34 ng/mL); mean Gleason grade, 6.8 (2-9); and mean prostate volume 34.9 mL (12-124). Surgical variables recorded included: console setup time, 10.8 min (6-47): console operation time, 125 min (90-315); mean bleeding, 150 mL (50-1150); and a 3.6% (9/250) transfusion rate. There was no peroperative mortality, and no conversion to open or laparoscopic surgery was required. Ninety-six percent of patients (240/250) had an adequate postoperative course, with a mean hospital stay of 4.2 days (3-35) and urinary catheter removal after 8 (5-28) days. Overall complication rate was 10.6%, with major complications occurring in only 3.2% of patients (8/250) and consisting of five surgical and three medical complications. Repeat surgery was required in 1.6% of cases (4/250) due to late peritonitis for cecal perforation, bleeding from epigastric artery, perineal percutaneous drainage of retrovesical hematoma, and pelvic urinoma after bladder catheter dislodgment. One patient required selective arterial embolization for persistent hematuria due to vesical artery fistula. Medical complications included acute renal failure due to thrombotic purpura resolved with hemodialysis in one patient and late pulmonary embolism managed with anticoagulation in two patients. Robot malfunction with no surgical implications or need for surgical conversion occurred in four patients (1.6%). Surgical maneuvers required to resolve late complications included one umbilical hernia repair, one meatotomy for meatal stenosis, one bladder neck endoscopic incision after contracture, and one endoscopic extraction of Hem-o-lok and vascular clip following erosion-migration into the bladder. CONCLUSIONS: Robotic radical prostatectomy is a safe and reproducible procedure with optimal functional and oncological results, a shorter learning curve, greater comfort and vision for surgeons, and a complication rate similar to and even better than reported for open and laparoscopic surgery series. Complications decrease with the learning curve, but surgical team experience continues to be the key factor to achieve better results.

Incidencias y complicaciones en nuestras primeras 250 prostatéctomias radicales robóticas / Complications and incidences in our first 250 robotic radical prostatectomies

Objetivo: EL objetivo del estudio es revisar la incidencia y analizar los factores que puedan contribuir a las complicaciones perioperatorias en los pacientes a los que se realiza una prostatectomía radical robótica basados en nuestra experiencia sobre 250 procedimientos. Material y métodos: Realizamos un estudio retrospectivo, descriptivo y analítico sobre 250 pacientes consecutivos a los que realizamos prostatectomía radical robótica durante un periodo de 3 años y 2 meses (enero 06–marzo 09). Se registran datos demográficos como: edad, PSA y grado de Gleason preoperatorio y volumen prostático. Todas las intervenciones fueron realizadas por tres cirujanos. Realizamos un abordaje laparoscópico transperitoneal con sistema robótico daVinci de 4 brazos. Empleamos un soporte informático Microsoft Excel. Los parámetros quirúrgicos recogidos son: tiempo de instalación, tiempo de consola, volumen de hemorragia, tasa de transfusión, estancia media y tiempo de sondaje uretral. Revisamos las incidencias y complicaciones intraoperatorias y postoperatorias precoces y tardías en esta serie de pacientes. Resultados: Los datos demográficos de la serie fueron: edad media de 61,15 años (47–74), PSA medio preoperatorio de 8,18ng/ml (2,6–34ng/ml), Gleason preoperatorio de 6,8 (2–9) y volumen prostático de 34,9cc (12–124cc). Los parámetros quirúrgicos recogidos son: tiempo de instalación: 10,2min (6–47min), tiempo de consola 125min (90–315min), hemorragia media de 150ml (50–1150ml) con una tasa de transfusión del 3,6% (9/250). No se registró mortalidad perioperatoria, ni fue preciso realizar ninguna reconversión a cirugía abierta o laparoscópica en los 250 procedimientos. Un total del 96% pacientes (240/250) tuvieron un curso postoperatorio adecuado sin incidencias reseñables con una estancia media de 4,2 días (3–35 días) y retirada de sonda vesical a los 8 días (5–28días). La tasa global de complicaciones es del 10,4% con solo 3,2% de complicaciones mayores (8/250): 5 complicaciones quirúrgicas y 3 médicas. La tasa de reintervención del 1,6% (4/250): una peritonitis tardía por perforación cecal, 1 hemorragia por lesión de arteria epigástrica, 1 drenaje perineal percutáneo de hematoma retrovescial y una revisión por urinoma tras desalojo accidental de sonda vesical. Un paciente preciso embolización arterial selectiva por hematuria tardía persistente tras fistula de arteria vesical superior. Entre las complicaciones médicas: 1 caso de fracaso renal agudo por púrpura trombótica trombocitopénica resuelto mediante hemodiálisis, y 2 embolias pulmonares tardía resueltas mediante anticoagulación. Se registraron 4 fallos del sistema robótico (1,6%) sin implicación ni necesidad de reconversión quirúrgica. Entre las complicaciones tardías que precisaron alguna maniobra quirúrgica para su resolución destacan: una reparación de hernia umbilical, una meatotomía por estenosis de meato uretral, una incisión endoscópica de esclerosis de anastomosis y una extracción endoscópica de clip vascular metálico y Hem-o-lock tras erosión-migración vesical. Conclusiones: La prostatectomía radical robótica es una técnica segura y reproducible con óptimos resultados oncológicos y funcionales, con curva de aprendizaje más corta, con excelente ergonomía y visión para el cirujano y con una incidencia de complicaciones comparable e incluso favorable a las series de cirugía abierta y laparoscópica. Las complicaciones se reducen con la curva de aprendizaje sin olvidar que es la experiencia del equipo quirúrgico el factor clave para conseguir mejores resultados (AU)

Objective: To review the incidence of and analyze the factors contributing to perioperative complications in patients undergoing robotic radical prostatectomy in our experience of 250 procedures. Materials y methods: An analytical, descriptive, retrospective study was conducted of 250 consecutive patients who underwent robotic radical prostatectomy during a period of three years and two months (January 06–March 09). Data recorded included age, preoperative Gleason grade and PSA, and prostate volume. All procedures were performed by three surgeons through a transperitoneal approach using a four-arm daVinci robotic system. Microsoft Excel support was used. Surgical variables recorded included setup time, console operation time, mean bleeding, transfusion rate, hospital stay, and urethral catheterization time. Incidences and intraoperative and postoperative late and early complications in these patients were reviewed. Results: Demographic data recorded included: mean age, 61.5 years (47–74); mean preoperative PSA, 8.18ng/mL (2.6–34ng/mL); mean Gleason grade, 6.8 (2–9); and mean prostate volume 34.9mL (12–124). Surgical variables recorded included: console setup time, 10.8min (6–47): console operation time, 125min (90–315); mean bleeding, 150mL (50–1150); and a 3.6% (9/250) transfusion rate. There was no peroperative mortality, and no conversion to open or laparoscopic surgery was required. Ninety-six percent of patients (240/250) had an adequate postoperative course, with a mean hospital stay of 4.2 days (3–35) and urinary catheter removal after 8 (5–28) days. Overall complication rate was 10.6%, with major complications occurring in only 3.2% of patients (8/250) and consisting of five surgical and three medical complications. Repeat surgery was required in 1.6% of cases (4/250) due to late peritonitis for cecal perforation, bleeding from epigastric artery, perineal percutaneous drainage of retrovesical hematoma, and pelvic urinoma after bladder catheter dislodgment. One patient required selective arterial embolization for persistent hematuria due to vesical artery fistula. Medical complications included acute renal failure due to thrombotic purpura resolved with hemodialysis in one patient and late pulmonary embolism managed with anticoagulation in two patients. Robot malfunction with no surgical implications or need for surgical conversion occurred in four patients (1.6%). Surgical maneuvers required to resolve late complications included one umbilical hernia repair, one meatotomy for meatal stenosis, one bladder neck endoscopic incision after contracture, and one endoscopic extraction of Hem-o-lok and vascular clip following erosion-migration into the bladder. Conclusions: Robotic radical prostatectomy is a safe and reproducible procedure with optimal functional and oncological results, a shorter learning curve, greater comfort and vision for surgeons, and a complication rate similar to and even better than reported for open and laparoscopic surgery series. Complications decrease with the learning curve, but surgical team experience continues to be the key factor to achieve better results (AU)

Prostatectomía radical: comparación de los resultados obtenidos durante las curvas de aprendizaje de la técnica laparoscópica pura y de la técnica asistida por robot con la prostatectomía radical retropúbica / Radical prostatectomy: evaluation of learning curve outcomes laparoscopic and robotic-assisted laparoscopic techniques with radical retropubic prostatectomy

Introducción: La prostatectomía radical retropúbica (PRR) es el patrón oro para el tratamiento quirúrgico del cáncer de próstata organoconfinado. Se están desarrollando técnicas quirúrgicas menos invasivas, como prostatectomía radical laparoscópica (PRL) y la prostatectomía radical asistida por robot (PRAR). El objetivo del estudio es comparar los resultados de la curva de aprendizaje de la PRL y de la PRAR con los de la PRR, especialmente la duración de la intervención quirúrgica. Material y métodos: Realizamos un estudio observacional retrospectivo Seleccionamos todas las PRR desde Enero de 2000, todas las PRL realizadas en el Hospital de Galdakao y las primeras 60 PRAR realizadas por el Grupo de Urología Clínica. Se evaluaron los parámetros operatorios y perioperatorios y las complicaciones quirúrgicas, comparando posteriormente las tres técnicas. Resultados: La duración de la intervención fue de 210 min en la PRR, 345 min en la PRL y 210 en la PRAR (p < 0,001). El sangrado intraoperatorio fue de 1500 ml en la PRR, 1275 ml en la PRL y 400 ml en la PRAR (p < 0,001). A los 6 meses de la intervención la tasa de continencia era del 60% en el grupo de PRAR, del 45,90% en el grupo de PRR y del 36,40% en el grupo de PRL (p = 0,001). Conclusiones: La PRL requiere un aprendizaje más largo que la PRAR. La PRAR nos ha permitido terminar la intervención en el mismo tiempo que la PRR. En nuestro medio la PRAR demostró ser beneficiosa en términos de estancia postquirúrgica y desangrado (AU)

Introduction/objective: Radical retropubic prostatectomy (RRP) is the gold standard for the surgical treatment of localized prostate cancer. New techniques are being developed with less invasive methods, including laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic radical prostatectomy (RALP). The aim of the study is to compare LRP and RALP outcomes during the learning curve with RRP, especially operative time and surgical complications. Material and method: We performed a retrospective observational study of all the RRP cases attended from January 2000, all the LRPs performed at the Urology Department of the Galdakao Usansolo Hospital and the first 60 RALPs treated by the Clínic Urology group. Baseline parameters, operative and perioperative parameters (nerve preservation, positive margins, intraoperative bleeding, duration of catheterization, hospital stay) and surgical complications were assessed, and the three techniques were compared. Results: The total number of patients was 192. The mean time operation was of 210 min in the RRP group, 345 min in the LRP group and 209.5 min in the RALP group (p = 0). Intraoperative bleeding was of 1500 mL in RRP, 1275 mL in LRP and 400mL in RALP (p = 0) (Table 1). Six months after the procedure the continence rate was 60% in the RALP group, 45.90% in the RRPgroup and 36.40% in the group LRP (p = 0.001) (Table 2). Conclusions: Laparoscopic radical prostatectomy requires a longer learning curve than robotic-assisted prostatectomy. Operative time in RALP procedures was comparable to RRP cases. RALP showed benefits in terms of continence and intraoperative bleeding (AU)

[Radical prostatectomy: evaluation of learning curve outcomes laparoscopic and robotic-assisted laparoscopic techniques with radical retropubic prostatectomy]. / Prostatectomía radical: comparación de los resultados obtenidos durante las curvas de aprendizaje de la técnica laparoscópica pura y de la técnica asistida por robot con la prostatectomía radical retropúbica.

INTRODUCTION/OBJECTIVE: Radical retropubic prostatectomy (RRP) is the gold standard for the surgical treatment of localized prostate cancer. New techniques are being developed with less invasive methods, including laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic radical prostatectomy (RALP). The aim of the study is to compare LRP and RALP outcomes during the learning curve with RRP, especially operative time and surgical complications. MATERIAL AND METHOD: We performed a retrospective observational study of all the RRP cases attended from January 2000, allthe LRPs performed at the Urology Department of the Galdakao Usansolo Hospital and the first 60 RALPs treated by the Clinic Urology group. Baseline parameters, operative and perioperative parameters (nerve preservation, positive margins, intraoperative bleeding, duration of catheterization, hospital stay) and surgical complications were assessed, and the three techniques were compared. RESULTS: The total number of patients was 192. The mean time operation was of 210 min in the RRP group, 345 min in the LRP group and 209.5 min in the RALP group (p = 0). Intraoperative bleeding was of 1500 mL in RRP, 1275 mL in LRP and 400 mL in RALP (p = 0) (Table 1). Six months after the procedure the continence rate was 60% in the RALP group, 45.90% in the RRP group and 36.40% in the group LRP (p = 0.001) (Table 2). CONCLUSIONS: Laparoscopic radical prostatectomy requires a longer learning curve than robotic-assisted prostatectomy. Operative time in RALP procedures was comparable to RRP cases. RALP showed benefits in terms of continence and intraoperative bleeding.

[Percutaneous kidney lithotripsy. Clinical course, indications, and current methodology in our Lithotripsy Unit]. / Litotricia renal percutánea. Evolución, indicaciones y metodología actual en nuestra Unidad de Litotricia.

OBJECTIVE: To review the history, development, indications and current methods of percutaneous renal lithotripsy. METHODS: The history and development of PNL is briefly reviewed. Its indications are analyzed, starting with large calculi and covering all the indications over the last 15 years of development of this technique and its current use. The PNL technique currently performed in our Lithotripsy Unit is described step by step. Technical details, equipment, instruments, complications and solutions are discussed. RESULTS/CONCLUSIONS: In our view, PNL continues to be the technique of choice for most of the calculi that are more than 2 cm in size. It is fundamental for the new generation of urologists to be familiar with all endourologic techniques since current technological advancements will allow us to perform procedures throughout the urinary tract using endoscopic methods.

[Surgical treatment of hypospadias. Our experience and follow up in 1993-1998]. / Tratamiento quirúrgico del hipospadias. Nuestra experiencia y seguimiento durante el período 1993-1998.

OBJECTIVE: To review our series of hypospadias. The incidence of the different types of hypospadias and the complication rates according to the different surgical techniques and materials utilized are analyzed. METHODS: We reviewed our series of 130 patients with hypospadias who underwent surgical correction at the Department of Pediatric Urology from 1993-1998. RESULTS: The patients presented the following types of hypospadias: glandular (13 cases), balano-preputial (56), distal penile (42), mid-penile (9), proximal penile (2) and penoscrotal hypospadias (8). The surgical techniques utilized were the Mickulitz meatotomy procedure (6 cases), MAGPI (24), Mathieu (77), Crawford (5), onlay (7), Duckett (3), Retik (4), Duplay (1), Denis-Brown (2) and penoscrotal transposition (1). The complications commonly observed were fistula (20 cases), hematoma (4), stricture of urethral meatus (4), infection (3), megaurethra (3), skin necrosis (1). CONCLUSIONS: Surgical repair of this developmental anomaly is performed when the patient is approximately 18 months old. In our series 15% of the patients developed fistula, which is similar to the complication rate reported in the literature. However, since we started using monofilament resorbable material, the incidence of fistula has dropped from 20% to approximately 5%. Although other factors are involved, the lower incidence of fistula formation may be largely due to a reduced tissue reaction to foreign body.

[Renal hematomas after extracorporeal lithotripsy with the lithotriptor "lithostar multiline de Siemens"]. / Hematomas renales tras litotricia extracorpórea con el litotriptor "lithostar multiline de siemens".

OBJECTIVE: Renal haematomas after extracorporeal shockwave lithotrity are an immediate and potentially serious complication. The incidence of post-ESWL renal haematoma with the new Siemens' Lithostar Multiline lithotripter is analyzed in an attempt to know its occurrence, predisposing factors and presentations signs and symptoms. MATERIAL AND METHODS: Between January and December 1998, a total of 1313 extracorporeal shockwave lithotrity sessions were performed on lithiasis located at any level of the urinary tract in 686 patients. Treatment were performed with a Lithostar Multiline lithotripter (electromagnetic generator). The power used ranged from 4 to 9 units, which are power steps based on load tension in Kv, pressure peaks in bars and energy flow density in mJ/mm2, with an average of 3800 pulses/session. A radiological study (ultrasound-tomography) was conducted when faced with clinical suspicion of complications. RESULTS: A total of 7 clinical renal haematomas (1.02%) were diagnosed. A conservative attitude was taken in most cases. One patient presented hemodynamic instability and required surgery to empty the haematoma and haemostasia of the renal unit, though no nephrectomy was finally required. As predisposing factors: presence of HBP, prior ESWL and hypercholesterolemia are all emphasized. In rare cases several factors concurred simultaneously in the same patient. CONCLUSIONS: Renal haematoma should be suspected in the presence of continuous or unjustified pain after ESWL treatment. Any likely coagulation disorder should be corrected, urinary infections ruled out and pressure figures controlled.

Hematomas renales tras litotricia extracorpórea con el litotriptor "lithostar multiline de siemens" / Renal haematoma after extracorporeal lithotrity using the siemens "lithostar multiline" lithotripter

OBJETIVO: Los hematomas renales tras litotricia extracorpórea por ondas de choque representan una complicación inmediata y potencialmente grave. Analizamos los casos de hematoma renal post-SWL con el nuevo litotriptor Lithosthar Multiline de Siemens, intentando conocer la incidencia, los factores predisponentes y la clínica de presentación. MATERIAL Y MÉTODOS: Entre Enero y Diciembre de 1998 se han realizado un total de 1.313 sesiones de litotricia extracorpórea por ondas de choque, sobre litiasis alojadas a cualquier nivel del tracto urinario en 686 pacientes. Los tratamientos fueron realizados con el litotriptor Lithostar Multiline (Generador Electromagnético). La potencia aplicada osciló entre 4-9 unidades, que son etapas de energía en base a tensión de carga en Kv, picos de presión en bares y densidad de flujo energético en mJ/mm2, con una media de 3.800 impulsos/sesión. Ante la sospecha clínica de complicaciones se realizó estudio radiológico (ecografía-tomografía). RESULTADOS: Se diagnosticaron un total de 7 hematomas renales clínicos (1,02 por ciento). En la mayoría de los casos se tomó una actitud conservadora. En un caso debido a la inestabilidad hemodinámica que presentó el paciente fue preciso intervención quirúrgica, evacuando el hematoma y realizando hemostasia de la unidad renal sin que fuera preciso realizar nefrectomía. Como factores predisponentes destacamos la presencia de HTA, ESWL previa e hipercolesterolemia, confluyendo en ocasiones varios factores en un mismo paciente. CONCLUSIONES: Debemos sospechar la presencia de un hematoma renal ante un dolor continuado o no justificado tras el tratamiento con ESWL. Es preciso corregir los posibles trastornos de la coagulación, descartar infección urinaria y control de las cifras tensionales (AU)

[Skin metastasis from transitional cell carcinoma of the bladder]. / Metástasis cutáneas de carcinoma de células transicionales de vejiga.

OBJECTIVE: To report an additional case of skin metastasis from transitional cell carcinoma of the bladder. The clinical features, distribution, differential diagnosis, treatment and survival are reviewed. METHODS: A 73-year-old patient with stage pT2 pN0 pMx carcinoma of the bladder is described. The imaging studies indicated tumor recurrence, but the patient refused reevaluation by endoscopy one year ago. RESULTS: An erythematous, nodular, indurated lesion extending from the hypogastrium to the proximal region of both lower limbs was found. The biopsy findings were compatible with metastatic spread from a carcinoma. CONCLUSION: Although skin metastasis from bladder carcinoma is rare, the number of cases reported is increasing. Skin metastasis is generally limited to the advanced stages of the disease and is an indication of poor prognosis.