Preliminary results of the external urinary sphincter Uroflex® on the quality of life of patients with male urinary incontinence after prostate surgery: tolerance, severity of incontinence, and quality of life.

PURPOSE: This study aims to establish the ability of the Uroflex® external artificial sphincter to reduce the severity of male urinary incontinence and improve the quality of life of patients with male urinary incontinence. METHODS: A pre-post pilot study was carried out on a sample of 30 patients with male urinary incontinence. Tolerability and satisfaction were assessed by comparing the results of the Pad test, and EQ-5D and KHQ questionnaires before and after 3 months of using Uroflex®. RESULTS: At 3 months, 76.6% of patients continued using Uroflex®. The median score for overall satisfaction with the device was 8 out of 10. Pad test showed a significant reduction in the severity of male urinary incontinence at 3 months (p < 0.001), with resolution of all symptoms in 31% of patients. The KHQ showed a significant improvement in global quality of life (p = 0.003). This was also significant for five of the nine specific dimensions assessed. There was also an improvement in self-rated health using the EQ-5D questionnaire, although not significant (p = 0.075). CONCLUSION: The Uroflex® external urinary sphincter seems to improve the severity of urinary incontinence and quality of life of patients with male urinary incontinence after prostate surgery. These encouraging results will need to be confirmed in larger controlled studies.

Addressing the Relationship Between Testosterone Levels and Urethral Stricture: A Case-Control Study.

PURPOSE: Hypoandrogenism may have an association with urethral stricture. This study aimed to identify and quantify the association between testosterone levels and urethral stricture. MATERIALS AND METHODS: A case-control study was conducted from January 2019 to January 2021. The case group included patients diagnosed with anterior urethral stricture who visited our urethral office of the urology department, while the control group included patients who visited our practice due to clinical conditions unrelated to voiding. In both groups, a 10 cc blood sample collection was scheduled between 7:30 and 9:30 a.m. The outcome was case/control status. The exposure variables were total testosterone, free testosterone, bioavailable testosterone, and hypoandrogenism (total testosterone < 300 ng/dL). The adjusted ORs were calculated for each exposure. Age, body mass index, hypertension, diabetes, smoking, and thyroxine levels were considered possible confounding factors. RESULTS: A total of 149 cases (mean age 59.5) were compared to 67 controls (64.3). Urethral stricture cases showed significantly lower mean total testosterone than controls (394 ng/dL vs 488 ng/dL). Similarly, the hypoandrogenism rate was significantly higher in the urethral stricture group (26% vs 7.5%). Each 100 unit increase in total testosterone was related to a 34% decrease in the odds of urethral stricture (adjusted OR 0.66, 95% CI: 0.51-0.86). Similarly, each increase of 1 unit of free testosterone and 10 units of bioavailable testosterone was associated with a decrease of 18% and 10%, respectively. A strong direct relationship was observed between hypoandrogenism and urethral stricture (adjusted OR 4.01, 95% CI: 1.37-11.7). CONCLUSIONS: Our study demonstrates an independent association between hypoandrogenism and anterior urethral stricture.

Fractura testicular por traumatismo cerrado / Testicular fracture by closed trauma

No disponible

Outcome of urethral strictures treated by endoscopic urethrotomy and urethroplasty.

INTRODUCTION: We analyze the outcomes of patients with urethral stricture who underwent surgical treatment within the past 5 years. METHODS: This is a retrospective study of male patients who underwent surgery for urethral stricture at our service from January 2008 to June 2012. We analyzed the comorbidities, type, length and location of the stricture and the surgical treatment outcome after endoscopic urethrotomy, urethroplasty or both. RESULTS: In total, 45 patients with a mean age of 53.7 ± 16.7 years underwent surgical treatment for urethral stricture. Six months after surgery, 46.7% of the patients had a maximum urinary flow greater than 15 mL/s, whereas 87.3% of the patients exhibited no stricture by urethrography after the treatment. The success rate in the patients undergoing urethrotomy was 47.8% versus 86.4% in those undergoing urethroplasty (p = 0.01). Twenty percent of the patients in whom the initial urethrotomy had failed subsequently underwent urethroplasty, thereby increasing the treatment success. CONCLUSION: In most cases, the treatment of choice for urethral stricture should be urethroplasty. Previous treatment with urethrotomy does not appear to produce adverse effects that affect the outcome of a urethroplasty if urethrotomy failed, so urethrotomy may be indicated in patients with short strictures or in patients at high surgical risk.

Urachal anomalies in children: surgical or conservative treatment?

OBJECTIVE: To shed light on the current controversy regarding the best treatment option for managing urachal anomalies in children. PATIENTS AND METHODS: A retrospective follow-up of a case series comprising 13 children who were diagnosed with urachal anomalies was performed. All cases were diagnosed between 2000 and 2011 and followed up at the Pediatric Urology Unit of San Cecilio University Hospital in Granada (Spain). Information about the baseline and follow-up variables was collected from clinical records. RESULTS: Nine of the 13 patients were symptomatic (6 patients with urachal cysts and 3 patients with urachal persistency). Conservative management was originally used in all but one case. During follow-up, reinfection appeared in two cases, and these patients were treated surgically. Spontaneous resolution was achieved in eight cases (61.5%). Two children with persistent urachal cysts are still being followed (4 and 6 years after the diagnosis), although ultrasound monitoring reveals a gradual reduction in the size of the cysts. The median time between diagnosis and resolution was 16.5 months. CONCLUSION: With the exception of cases in which there is a clear indication for surgery (i.e. reinfection), a conservative approach based on regular monitoring may be useful.

Endoscopic treatment of ureterovesical junction obstructive pathology: A description of the oblique meatotomy technique and results.

BACKGROUND: Benign obstructive pathology of the ureterovesical junction includes congenital and acquired illnesses. The objective of this study was to describe the endoscopic oblique meatotomy technique using scissors and cold cutting to treat benign obstructive pathology of the ureterovesical junction. METHODS: From 2007 to 2012, we treated 18 patients with obstructive pathology of the ureterovesical junction (5 megaureters [3 with lithiasis], 4 iatrogenic stenoses, and 9 ureteroceles with lithiasis). In all cases, oblique meatotomy was performed using endoscopic scissors through an 8.5 Ch ureteroscope. The mean follow-up for all patients was 3 years. Pain, grade of hydronephrosis, and occurrence of vesicoureteral reflux were evaluated before and after treatment. RESULTS: The mean endoscopic treatment time was 13.4 minutes. The procedure was performed on an outpatient basis with 6 hours of hospital admission, and a double J stent was inserted for 6 weeks. We achieved treatment success in 94.5% of patients after 3 years of follow-up. Only 1 patient presented with vesicoureteral reflux at 12 months after treatment; however, this condition did not require further treatment. Overall, 100% of patients remained free from lithiasis. There are 2 main limitations: the small number of patients and the lack of another group to compare the results of this technique; however, the aim of this work was to communicate a new technique to treat ureterovesical junction stricture. INTERPRETATION: Oblique ureteral meatotomy is a safe and effective treatment for benign obstructive pathology of the ureterovesical junction and has a low index of complications.

Vesicoureteral refulx in overactive bladder: medical resolution through botulin toxin injection.

OBJECTIVE: Overactive bladder may have a neurogenic or non neurogenic origin. Sometimes, as a result of detrusor overactivity, disorders of the upper urinary tract function may appear. One of these alterations may be the appearance of associated vesicoureteral reflux. The treatment of overactive bladder may be done with anticholinergic drugs and if there is not response the use of botulin toxin type A is approved. The aim of this case report is to demonstrate the effect of botulin toxin type A in the treatment of overactive bladder and vesicoureteral reflux secondary to the overactive bladder. METHOD: We present the case of a 10-year-old patient without significant past medical history. When he was one year old he had a urinary infection and voiding cystourethrogram showed grade 1 right vesicoureteral reflux. When he was 4 year old he presented several episodes of pyelonephritis and then he was diagnosed of severe bilateral vesicoureteral reflux, which did not respond to treatment with Macroplastic ® or Deflux ®. Urodynamic study was performed showing overactive bladder with decreased bladder compliance. RESULTS: We performed intravesical injection of 200 U of botulin toxin type A and vesicoureteral reflux disappeared and urodynamic study improved. One year later we re-injected botulin toxin type A (300 U) and we repeated the injection after one year (300 U). The patient is currently well, without changes in the urodynamic study and without vesicoureteral reflux. CONCLUSION: Repeated injections of botulin toxin type A has shown great efficacy in the treatment of overactive bladder in children with vesicoureteral reflux improved secondary.

Reflujo vesicoureteral en vejiga hiperactiva: resolución con inyección de toxina botulínica / Vesicoureteral refulx in overactive bladder: medical resolution through botulin toxin injection

OBJETIVO: La vejiga hiperactiva puede tener un origen neurogénico o no neurogénico. En ocasiones, como consecuencia de dicha hiperactividad del detrusor pueden producirse alteraciones en la funcionalidad del tracto urinario superior. Una de esas alteraciones puede ser la aparición de reflujo vesicoureteral asociado. El tratamiento de dicha vejiga hiperactiva puede hacerse con anticolinérgicos y en caso de no presentar respuestas, está aprobado el uso de toxina botulínica tipo A. El objetivo es demostrar el efecto de la toxina botulínica tipo A en el tratamiento de la vejiga hiperactiva y del reflujo vesicoureteral secundario a la misma. MÉTODO: Presentamos el caso de un paciente de 10 años sin antecedentes personales de interés que al año de vida presentó infección urinaria y en cistouretrografía miccional seriada tenía reflujo vesicoureteral derecho grado 1. A los 4 años de edad presentó varios episodios de pielonefritis diagnosticándose de reflujo vesicoureteral severo bilateral no respondiendo a tratamiento con macroplastic® ni deflux®. Se realizó estudio urodinámico observando vejiga hiperactiva con disminución de la acomodación vesical. RESULTADOS: Se realizó inyección intravesical de 200 U de toxina botulínica tipo A observando remisión del reflujo vesicoureteral y mejoría en el estudio urodinámico. Al año se vuelve a inyectar toxina botulínica tipo A (300 U) y se repite un año después la inyección de 300 U, estando actualmente el paciente bien, sin alteraciones en el estudio urodinámico y sin reflujo vesicoureteral. CONCLUSIÓN: La inyección repetida de toxina botulínica tipo A ha demostrado gran eficacia en el tratamiento de la vejiga hiperactiva en niños con mejoría del reflujo vesicoureteral secundario(AU)

OBJECTIVE: Overactive bladder may have a neurogenic or non neurogenic origin. Sometimes, as a result of detrusor overactivity, disorders of the upper urinary tract function may appear. One of these alterations may be the appearance of associated vesicoureteral reflux. The treatment of overactive bladder may be done with anticholinergic drugs and if there is not response the use of botulin toxin type A is approved.The aim of this case report is to demonstrate the effect of botulin toxin type A in the treatment of overactive bladder and vesicoureteral reflux secondary to the overactive bladder. METHOD: We present the case of a 10-year-old patient without significant past medical history. When he was one year old he had a urinary infection and voiding cystourethrogram showed grade 1 right vesicoureteral reflux. When he was 4 year old he presented several episodes of pyelonephritis and then he was diagnosed of severe bilateral vesicoureteral reflux, which did not respond to treatment with Macroplastic ® or Deflux ®. Urodynamic study was performed showing overactive bladder with decreased bladder compliance. RESULTS: We performed intravesical injection of 200 U of botulin toxin type A and vesicoureteral reflux disappeared and urodynamic study improved. One year later we reinjected botulin toxin type A (300 U) and we repeated the injection after one year (300 U). The patient is currently well, without changes in the urodynamic study and without vesicoureteral reflux. CONCLUSION: Repeated injections of botulin toxin type A has shown great efficacy in the treatment of overactive bladder in children with vesicoureteral reflux improved secondary(AU)

Randomized clinical trial on antimicrobial prophylaxis for flexible urethrocystoscopy.

OBJECTIVES: One of the main drawbacks of flexible urethrocystoscopy is the risk of urinary tract infection (UTI). In order to reduce this risk, antimicrobial prophylaxis has been considered, however there is not a unanimous view regarding indications, dosage, type of antibiotic, and so on. To clarify this uncertainty, we practiced a pilot and experimental study aimed at assessing the effectiveness of chemoprophylaxis with 3 grams of fosfomycin trometamol in the prevention of UTI after urethrocystoscopy. METHODS: Sixty patients were entered into a pilot randomized clinical trial between March and August 2011. Thirty patients were assigned to a control group without receiving any antibiotic dose, and the intervention group (30 patients) received 3 g fosfomycin trometamol. Ten days later urine culture and sediment analysis were performed in all patients. Significant bacteriuria was considered from > 105 CFU /ml. One month later a telephone survey was developed to assess urinary symptoms, and assistance to the family doctor. We estimated the cumulative incidence of bacteriuria, pyuria and microhematuria in both groups, and we compared the results using a strategy of analysis per protocol and intention to treat. RESULTS: The incidence of bacteriuria, pyuria and microhematuria in the control group was 10%, 23.3% and 26.7% respectively and in the intervention groups the values differed depending on the type of analysis. Considering only the 27 patients (per protocol analysis), the incidence would be 11.1%, 37.0% and 29.6% respectively. If we include the three patients who did not completed the study (per intention to treat analysis) and considering their results as negative, the results were 10%, 33.3% and 26.7% respectively. Finally, in the case the three cultures not performed in this group had produced a positive result, the impact would have been 20.0%, 43.3% and 36.7%. In any of the three cases, the differences with the control group were not statistically significant. CONCLUSIONS: In a selected population and with appropriate aseptic measures, antibiotic chemoprophylaxis does not appear to show a clinically relevant reduction in the incidence of UTI in patients undergoing flexible urethrocystoscopy.

Gross calcification on distal end of ureteral stent.

OBJECTIVE: The commonest indications for ureteral stent placement are: obstructive nephrolithiasis, renoureteral surgery, urologic oncology, endourology and extrinsic ureteral compression. METHODS: We report the case of a 77-year-old male patient with a DJ ureteral catheter placed for an 8-month period and history of nephrolithiasis; the stent showed a 60 mm x 30 mm calcification on its distal end. RESULTS: Open cystolithotomy and removal of stent resolved the clinic symptomatology. CONCLUSION: A prolonged indwell time of stents, as well as a history of nephrolithiasis and urinary infections may on many occasions result in calcification and encrustation of ureteral stents, and will lead to the use of endourology techniques, extracorporeal lithotripsy or open surgery to resolve these conditions.

Calcificación gigante en extremo distal de stent ureteral / Gross calcification on distal end of ureteral stent

OBJETIVO: Las indicaciones más habituales para la colocación de un stent ureteral son nefrolitiasis obstructivas, cirugía nefroureteral, oncología urológica, endourología, compresión ureteral extrínseca y como apoyo previo al tratamiento con LEOC.MÉTODOS: Presentamos un caso de un varón de 77 años de edad con catéter ureteral DJ colocado durante 8 meses y con antecedentes personales de nefrolitiasis que presenta calcificación de 60 mm x 30 mm de extremo distal del mismo.RESULTADOS: Se realizó cistolitotomía abierta y extracción del stent que solventó el cuadro. La composición del cálculo fue fosfato amónico magnésico con trazas de urato amónico y fosfato cálcico.CONCLUSIÓN: En muchas ocasiones la persistencia prolongada de dicho stent, junto con antecedentes de nefrolitiasis e infección urinaria predispone a la calcificación y encrustamiento de dicho catéter ureteral, siendo necesarias técnicas de endourología, litotricia extracorpórea o cirugía abierta para la resolución de dichos cuadros (AU)

OBJECTIVE: The commonest indications for ureteral stent placement are: obstructive nephrolithiasis, renoureteral surgery, urologic oncology, endourology and extrinsic ureteral compression.METHODS: We report the case of a 77-year-old male patient with a DJ ureteral catheter placed for an 8-month period and history of nephrolithiasis; the stent showed a 60 mm x 30 mm calcification, on its distal end.RESULTS: Open cystolithotomy and removal of stent resolved the clinic symptomatology.CONCLUSION: A prolonged indwell time of stents, as well as a history of nephrolithiasis and urinary infections may on many occasions result in calcification and encrustation of ureteral stents, and will lead to the use of endourology techniques, extracorporeal lithotripsy or open surgery to resolve these conditions (AU)

[Current indications of open surgery for the treatment of renal lithiasis. Ureterocalycostomy as definitive treatment for lithiasis in a female with recurrent disease]. / Indicación actual de la cirugía abierta en el tratamiento de la litiasis renal. Ureterocalicostomía como tratamiento definitivo de litiasis en mujer con patología recidivante.

OBJECTIVE: We describe one case of recurrent lithiasis associated with anatomical alteration of the renal pelvis related to previous surgery. METHODS/RESULTS: The patient presented a urinary tract infection episode, complicated with pyonephrosis and septicemia. In the intravenous urography, infectious radiopaque pyelocaliceal multiple and complex lithiasis can be seen, as well as kidney hydronephrosis grade III-IV. Important pyelic sclerosis secondary to previous surgery on the renal unit was seen. Nephrectomy was performed with lower pole nephro-lithotomy and reconstruction of the upper urinary tract through ureterocalicostomy. Two and a half years after surgery, control urogram shows absence of urolithiasis and a slight delay of renal function. CONCLUSIONS: Ureterocalicostomy is indicated in cases of ureteropelvic junction obstruction associated with intrarenal pelvis caused by alterations of fusion, rotation or location of kidney. It is also indicated in cases of severe peripyelic fibrosis secondary to previous pyeloplasty failure or renal surgery. In our case, in addition to the infectious component of lithiasis, an anatomical alteration, probably secondary to previous surgery, caused the chronification of lithiasis. Facing such suspicion a surgical management was undertaken to eliminate the lithiasis and get a correct derivation of the working area of the kidney, in order to prevent further recurrences.

Indicación actual de la cirugía abierta en el tratamiento de la litiasis renal. Ureterocalicostomía como tratamiento definitivo de litiasis en mujer con patología renal / Current indications of open surgery for the treatment of renal lithiasis. Ureterocalycostomy as definitive treatment for lithiasis in a female with recurrent dis

OBJETIVO: Presentamos un caso de litiasis recidivante asociado a alteración anatómica de la pelvis renal secundaria a cirugía.MÉTODOS/RESULTADOS: La paciente presenta un episodio de infección urinaria complicada con pionefrosis y septicemia. En la urografía intravenosa se observa litiasis radiodensa infecciosa, pielolocalicial múltiple compleja, sobre riñón con hidronefrosis grado III-IV por importante esclerosis piélica secundaria a cirugía previa sobre dicha unidad renal. Se realiza nefrectomía polar inferior con nefrolitotomía y reconstrucción de la vía urinaria superior mediante uréterocalicostomía. Dos años y medio después de la cirugía la urografía de control refleja ausencia de litiasis y leve retraso de la función renal.CONCLUSIONES: La ureterocalicostomía está indicada en casos de obstrucción de la unión ureteropiélica asociada a una pelvis intrarrenal por alteraciones de la fusión, rotación o localización renal, y en casos de fibrosis peripiélica severa secundaria a una pieloplastía fallida o cirugía renal previa. En el caso presentado además del componente infeccioso de las litiasis, una alteración anatómica, probablemente secundaria a la cirugía previa, provocaba una perpetuación de la clínica litiásica. Ante tal sospecha se impuso una solución de tipo quirúrgico que solucionara en un tiempo tanto la eliminación de la litiasis como una correcta derivación de la zona funcionante del riñón para evitar recidivas posteriores(AU)

OBJECTIVE: We describe one case of recurrent lithiasis associated with anatomical alteration of the renal pelvis related to previous surgery.METHODS/RESULTS: The patient presented a urinary tract infection episode, complicated with pyonephrosis and septi-cemia. In the intravenous urography, infectious radiopaque pyelocaliceal multiple and complex lithiasis can be seen, as well as kidney hydronephrosis grade III-IV. Important pyelic sclerosis secondary to previous surgery on the renal unit was seen. Nephrectomy was performed with lower pole nephro-lithotomy and reconstruction of the upper urinary tract through ureterocalicostomy. Two and a half years after surgery, control urogram shows absence of urolithiasis and a slight delay of renal function.CONCLUSIONS: Ureterocalicostomy is indicated in cases of ureteropelvic junction obstruction associated with intrare-nal pelvis caused by alterations of fusion, rotation or location of kidney. It is also indicated in cases of severe peripyelic fibrosis secondary to previous pyeloplasty failure or renal sur-gery. In our case, in addition to the infectious component of lithiasis, an anatomical alteration, probably secondary to previous surgery, caused the chronification of lithiasis. Fa-cing such suspicion a surgical management was undertaken to eliminate the lithiasis and get a correct derivation of the working area of the kidney, in order to prevent further recu-rrences(AU)

Tratamiento de la litiasis vesical con láser / The treatment of bladder lithiasis with laser

OBJETIVO: El uso del láser para litotricia endoscópica, comienza en 1968 al utilizar Mulvaney un láser de rubí sin éxito, posteriormente se probaron láser de CO2 y Neodymio-YAG. Con el láser pulsado de colorante y el láser de alexandrita se obtienen unos rendimientos energéticos que oscilan de 30 a 200 mJ, su capacidad de fragmentación no es universal y esta limitada a pequeños cálculos, generalmente ureterales, por lo que no han sido alternativa terapéutica en la litiasis vesical. El láser de Holmio genera pulsos de energía de 400-2500 mJ, capaz de fragmentar todo tipo de cálculos. El Objetivo de este trabajo es analizar los resultados de la litotricia vesical endoscópica con láser de holmio YAG. MÉTODOS: En el periodo de 2006-2008 hemos tratado 21 casos de litiasis vesical, con tamaños de 1 a 4 cm. en pacientes de 8-76 años, 6 mujeres y 15 hombres, que corresponden a: Cuatro casos de litiasis infantil, 3 de ácido úrico, 1 caso de cistina, litiasis de oxalato y/o fosfato cálcico en 7 casos, 5 casos de litiasis vesical sobre extremo inferior de doble jota, 1 caso de litiasis en ureterocele intravesical. El tratamiento se ha realizado con un equipo Dornier Medilas de 20 watios de Holmio-YAG como fuente de energía, que se ha aplicado a través de cistoscopios infantil-adulto o ureteroscopios de 7-8.5 Ch. semirrígido y flexible. El control post-operatorio se ha realizado con radiografía simple de aparato urinario y ecografía. Realizamos estudio de factores de riesgo litógeno y análisis de los fragmentos del cálculo. RESULTADOS: Los 21 casos descritos corresponden a litiasis vesical secundaria o tipo II. En todos los casos se ha comprobadola ausencia de litiasis residual con estudios de imagen y se han corregido los factores de riesgo litógeno con procedimientos médicos o quirúrgicos. CONCLUSIONES: Consideramos que hoy, la litotricia vesical endoscópica con láser de holmio si es alternativa terapéutica. A pesar de que existen múltiples opciones de tratamiento endoscópico,la litotricia transuretral con láser de holmio ofrece buenos resultados con un bajo porcentaje de complicaciones (AU)

OBJECTIVES: The use of laser for endoscopic lithotripsy started in 1968 when Mulvaney tried a ruby laser without success; Later on, the CO2 laser and the Nd: YAG were tried. With the pulsed dye and alexandrite lasers energetic performances between 30 and 200 mJ are obtained, their capacity of fragmentation is not universal and is limited to small stones, generally ureteral stones, so that it has not been a therapeutic alternative for bladder lithiasis. The holmium laser generates energy pulses of 400-2500mJ, it is able to fragment every type of stone. The objective of this work is to analyze the results of endoscopic bladder lithotripsy with holmium-YAG laser. METHODS: In the period between 2006-2008 we treated 21 cases of bladder lithiasis, with a stone size between 1 and 4 cm in patients from 8-76 years, six women and 15 men, which correspond to: four cases of infantile lithiasis, 3 of uric acid, one case of cystine, seven cases of calcium oxalate and/or phosphate, five cases of bladder lithiasis growing around a double J catheter, and one case of lithiasis within an intravesical ureterocele. Treatment was performed with a 20W Dornier Medilas holmium-YAG equipment, applied using children/adult cystoscopes or 7-8.5 Ch ureteroscopes, both semirigid and flexible. Post operative control included KUB x-ray and ultrasound. We performed a study of lithogenic risk factors and stone fragments analysis. RESULTS: The 21 cases described are all secondary or type II bladder lithiasis. In all cases the absence of residual lithiasis was checked with imaging studies and the lithogenic risk factors were corrected with medical or surgical procedures. CONCLUSIONS: We consider that today bladder endoscopic lithotripsy with holmium laser is a therapeutic alternative. Despite there are multiple options for endoscopic treatment, transurethral lithotripsy with holmium laser offers good results with a low complication rate (AU)

[Clinical and radiological criteria for the therapeutic decision for vesicoureteral refux. Retrospective analysis of our experience]. / Criterios clínicos y radiológicos en la decisión terapéutica del reflujo vesicoureteral. Un análisis retrospectivo de nuestra experiencia.

OBJECTIVES: According to our experience, we present a proposal for the treatment of vesicoureteral reflux, based on both clinical and radiological evidences. We also describe how the introduction of endoscopic procedures has influenced the evolution of treatment indications as well as the time intervals for treatment. METHODS: We have analysed all cases of vesicoureteral reflux treated in our Department in two periods of similar length: The first one (106 patients) comprised from 1995 to March 2001 (when endoscopic procedures were introduced). The second one (138 patients), comprised from March, 2001 to March 2007. Clinical, diagnostic, therapeutic and outcome-related variables were studied for all cases. RESULTS: The number of patients was higher in the second period. In this period the number of cases requiring ureteral reimplantation decreased with respect to the first one (from 24 to 7). The success rate with endoscopic treatment reached 94.9%, with no significant differences regarding age or grade of reflux, although higher rates of failures were observed in children aged less than 3 years old and in high-grade reflux. The association of reflux with other malformations was not related with a worse evolution after treatment. CONCLUSIONS: Endoscopic treatment, due to its similar efficacy and low aggressiveness, should be considered a valid alternative to open surgery (which offers good results but non-negligible comorbidity) for persistent reflux in which medical treatment has not been useful. We propose a tentative therapeutic scheme to establish the indications for each type of treatment depending on the grade of reflux and its clinical evolution.

Criterios clínicos y radiológicos en la decisión terapéutica del reflujo vesicoureteral. Un análisis retrospectivo de nuestra experiencia / Clinical and radiological criteria for the therapeutic decision for vesicoureteral reflux. Retrospective analysis of our experience

Objetivo: Establecer, en base a nuestra experiencia, unos esquemas terapéuticos del reflujo vesicoureteral en el niño, apoyándonos en resultados clínicos y radiológicos, observando cómo han ido evolucionando las indicaciones y tiempos de tratamiento con el advenimiento de las técnicas endoscópicas. Métodos: Se han analizado los pacientes con reflujo vesicoureteral tratados en dos periodos de similar duración: el primero (106 pacientes), entre 1995 y marzo 2001 (fecha en que se introdujeron las técnicas endoscópicas); el segundo, (138 pacientes), desde esa fecha hasta marzo de 2007. En todos los pacientes se estudiaron variables clínicas, diagnósticas y terapéuticas, así como el resultado obtenido. Resultados: El número de pacientes tratados aumentó en el segundo período, en él disminuyó ostensiblemente (de 24 a 7) el número de pacientes que requirieron reimplantación vesicoureteral. La proporción de éxitos del tratamiento endoscópico ascendió al 94,9%, no apreciándose diferencias significativas en función de la edad o el grado de reflujo, aunque se observa un mayor porcentaje de fracasos en niños menores de 3 años y en reflujos de alto grado. La presencia de malformaciones asociadas no se relacionó con una peor evolución tras el tratamiento. Conclusiones: En aquellos reflujos donde el tratamiento médico no ha sido eficaz, persistiendo o empeorando el mismo, y como alternativa a la cirugía abierta (con buenos resultados pero con una morbilidad no desdeñable), el tratamiento endoscópico se convierte en una alternativa de eficacia similar y mínimamente agresiva. Proponemos un esquema orientativo para establecer las indicaciones de cada estrategia terapéutica en función del grado de reflujo y su evolución clínica (AU)

Objectives: According to our experience, we present a proposal for the treatment of vesicoureteral reflux, based on both clinical and radiological evidences. We also describe how the introduction of endoscopic procedures has influenced the evolution of treatment indications as well as the time intervals for treatment. Methods: We have analysed all cases of vesicoureteral reflux treated in our Department in two periods of similar length: The first one (106 patients) comprised from 1995 to March 2001 (when endoscopic procedures were introduced). The second one (138 patients), comprised from March, 2001 to March 2007. Clinical, diagnostic, therapeutic and outcome-related variables were studied for all cases. Results: The number of patients was higher in the se-cond period. In this period the number of cases requiring ureteral reimplantation decreased with respect to the first one (from 24 to 7). The success rate with endoscopic treatment reached 94,9%, with no significant differences regarding age or grade of reflux, although higher rates of failures were observed in children aged less than 3 years old and in high-grade reflux. The association of reflux with other malformations was not related with a worse evolution after treatment. Conclusions: Endoscopic treatment, due to its similar efficacy and low aggressiveness, should be considered a valid alternative to open surgery (which offers good results but non-negligible comorbidity) for persistent reflux in which medical treatment has not been useful. We propose a tentative therapeutic scheme to establish the indications for each type of treatment depending on the grade of reflux and its clinical evolution (AU)

[The treatment of bladder lithiasis with laser]. / Tratamiento de la litiasis vesical con láser.

OBJECTIVES: The use of laser for endoscopic lithotripsy started in 1968 when Mulvaney tried a ruby laser without success; Later on, the CO2 laser and the Nd:YAG were tried. With the pulsed dye and alexandrite lasers energetic performances between 30 and 200 mJ are obtained, their capacity of fragmentation is not universal and is limited to small stones, generally ureteral stones, so that it has not been a therapeutic alternative for bladder lithiasis. The holmium laser generates energy pulses of 400-2500 mJ, it is able to fragment every type of stone. The objective of this work is to analyze the results of endoscopic bladder lithotripsy with holmium-YAG laser. METHODS: In the period between 2006-2008 we treated 21 cases of bladder lithiasis, with a stone size between 1 and 4 cm in patients from 8-76 years, six women and 15 men, which correspond to: four cases of infantile lithiasis, 3 of uric acid, one case of cystine, seven cases of calcium oxalate and/or phosphate, five cases of bladder lithiasis growing around a double J catheter, and one case of lithiasis within on intravesical ureterocele. Treatment was performed with a 20W Dornier Medilas holmium-YAG equipment, applied using children/adult cystoscopes or 7-8.5 Ch ureteroscopes, both semirigid and flexible. Post operative control included KUB x-ray and ultrasound. We performed a study of lithogenic risk factors and stone fragments analysis. RESULTS: The 21 cases described are all secondary or type II bladder lithiasis. In all cases the absence of residual lithiasis was checked with imaging studies and the lithogenic risk factors were corrected with medical or surgical procedures. CONCLUSIONS: We consider that today bladder endoscopic lithotripsy with holmium laser is a therapeutic alternative. Despite there are multiple options for endoscopic treatment, transurethral lithotripsy with holmium laser offers good results with a low complication rate.