[Holmium laser prostate enucleation. All we should aim for.] / Enucleación prostática con láser de holmio. A lo que todos deberíamos aspirar.

OBJECTIVE: Prostate enucleation is becoming more relevant within BPH treatment. Nowadays is probably the gold standard for enucleation. Several studies have shown holmium laser as the most frequently used safe and efficient energy source. The long learning curve remains as its major drawback. The current review aims to describe step to step technique at our institutionand describing the rational for its use. METHODS: A detailed description on our  step-to-step Holep technique is provided. We focused on the main differences with other techniques already described highlighting the largest experience reported. RESULTS: None of the published series has shown better results in terms of functional, safety and less complications outcomes on the short and long term. No differences are shown in terms of intraoperative/postoperative blood loss, reoperations, capsular perforations or urethral strictures. Our techniques provides shorter surgical length and improved efficiency than blocking and trilobular techniques. The rates of early continence are 4% vs5-40%. Lastly, improvement in morcellator devices delivered no complications related to that part of the surgery. CONCLUSIONS: Holep is the gold standard technique for prostate enucleation. It provides improved functional and safety outcomes than with other techniques. A standardized and optimized technique is mandatory.

OBJETIVO: La enucleación prostática se ha abierto camino dentro de la cirugía de la hiperplasia benigna de próstata (HBP) hasta convertirse en su técnica de referencia. Numerosos estudios avalan especialmente al láser de holmio (HoLEP) como la fuente de energía más representativa, segura y eficaz. Sin embargo, su larga curva de aprendizaje sigue dificultando su implantación. El propósito de esta revisión es describir paso a paso la técnica quirúrgica que empleamos en nuestro centro para ayudar a la extensión de la HoLEP, así como demostrar por qué creemos que esta variante es la más eficaz y eficiente de todas las variantes disponibles.MÉTODOS: Hemos realizado una detallada descripción paso a paso de nuestra técnica de enucleación prostática con láser de holmio, centrándonos en las principales diferencias que presenta con las variantes más extendidas y haciendo incapié en sus fortalezas frente a las series con más experiencia. RESULTADOS: Ninguna de las series publicadas hasta la fecha ha demostrado mejores resultados funcionales, mayor seguridad o menores complicaciones a corto o largo plazo que los datos de nuestra serie. No hay diferencias en cuanto a sangrado intra o post-operatorio, reintervenciones, perforaciones de cápsula o estenosis de uretra. Nuestra serie tiene mejores tiempos quirúrgicos que cualquier otra, demostrando una mayor eficiencia que técnicas en bloque o trilobulares. Todo ello logrando unas tasas de continencia temprana o inmediata iguales o mejores (4% vs 5-40%). Por último,el uso de dispositivos de morcelación mejorados hace que carezcamos de complicaciones durante esta fase del procedimiento. CONCLUSIONES: La HoLEP es la técnica de referenciaa la que debería aspirar cualquier servicio de urología moderno, aunando los mejores datos funcionales y de seguridad que se pueden obtener actualmente en el tratamiento de la HBP. Para ello es necesario disponer de una técnica estandarizada y optimizada que permita su máxima difusión.

Enucleación prostática con láser de holmio. A lo que todos deberíamos aspirar / Holmium laser prostate enucleation. All we should aim for

OBJETIVO: La enucleación prostática se ha abierto camino dentro de la cirugía de la hiperplasia benigna de próstata (HBP) hasta convertirse en su técnica de referencia. Numerosos estudios avalan especialmente al láser de holmio (HoLEP) como la fuente de energía más representativa, segura y eficaz. Sin embargo, su larga curva de aprendizaje sigue dificultando su implantación. El propósito de esta revisión es describir paso a paso la técnica quirúrgica que empleamos en nuestro centro para ayudar a la extensión de la HoLEP, así como demostrar por qué creemos que esta variante es la más eficaz y eficiente de todas las variantes disponibles. MÉTODOS: Hemos realizado una detallada descripción paso a paso de nuestra técnica de enucleación prostática con láser de holmio, centrándonos en las principales diferencias que presenta con las variantes más extendidas y haciendo incapié en sus fortalezas frente a las series con más experiencia. RESULTADOS: Ninguna de las series publicadas hasta la fecha ha demostrado mejores resultados funcionales, mayor seguridad o menores complicaciones a corto o largo plazo que los datos de nuestra serie. No hay diferencias en cuanto a sangrado intra o post-operatorio, reintervenciones, perforaciones de cápsula o estenosis de uretra. Nuestra serie tiene mejores tiempos quirúrgicos que cualquier otra, demostrando una mayor eficiencia que técnicas en bloque o trilobulares. Todo ello logrando unas tasas de continencia temprana o inmediata iguales o mejores (4% vs 5-40%). Por último, el uso de dispositivos de morcelación mejorados hace que carezcamos de complicaciones durante esta fase del procedimiento. CONCLUSIONES: La HoLEP es la técnica de referencia a la que debería aspirar cualquier servicio de urología moderno, aunando los mejores datos funcionales y de seguridad que se pueden obtener actualmente en el tratamiento de la HBP. Para ello es necesario disponer de una técnica estandarizada y optimizada que permita su máxima difusión

OBJECTIVE: Prostate enucleation is becoming more relevant within BPH treatment. Nowadays is probably the gold standard for enucleation. Several studies have shown holmium laser as the most frequently used safe and efficient energy source. The long learning curve remains as its major drawback. The current review aims to describe step to step technique at our institution and describing the rational for its use. METHODS: A detailed description on our step-to-step Holep technique is provided. We focused on the main differences with other techniques already described highlighting the largest experience reported. RESULTS: None of the published series has shown better results in terms of functional, safety and less complications outcomes on the short and long term. No differences are shown in terms of intraoperative/postoperative blood loss, reoperations, capsular perforations or urethral strictures. Our techniques provides shorter surgical length and improved efficiency than blocking and trilobular techniques. The rates of early continence are 4% vs 5-40%. Lastly, improvement in morcellator devices delivered no complications related to that part of the surgery. CONCLUSIONS: Holep is the gold standard technique for prostate enucleation. It provides improved functional and safety outcomes than with other techniques. A standardized and optimized technique is mandatory

Prone percutaneous nephrolithotomy: its advantages and our technique for puncture.

Percutaneous nephrolithotomy (PCNL) is considered the treatment of choice for large urinary calculi and staghorn lithiasis. The approach for this surgery may be either supine or prone, and different access techniques are described in the literature with the use of ultrasound, fluoroscopy, or both combined. We believe that prone PCNL offers to the urologist key advantages, such as the possibility of puncturing anatomically abnormal urinary tracts, to perform multiple percutaneous tracts in the same kidney, experiencing the vacuum cleaner effect, ease of exploring the upper calyx through the inferior calyx, possibility to perform endoscopic combined intrarenal surgery (ECIRS) and bilateral simultaneous surgery, and to performed over local anesthesia. An adequate training for the endourologist should include both the prone and supine techniques for PCNL and to know which patient can benefit the most from each one.

[Page kidney: subcapsular haematoma and arterial hypertension. A new case report and review of the literature]. / Ri˜ón de page: hematoma subcapsular renal e hipertensión arterial. Presentación de un nuevo caso y revisión de la literatura.

OBJECTIVE: We present the case of a spontaneous subcapsular renal hematoma with increase of the levels of blood pressure in a patient previously normotensive. METHODS: Patient with abdominal pain, spontaneous without previous trauma. CT showed a right subcapsular kidney hematoma. High levels of blood pressure were noticed at the admission in urology. CONCLUSION: Page kidney is a cause of arterial hypertension due to external compression of renal parenchyma. It could be unnoticed as essential hypertension if high suspicion is not taken into account. Nowadays, the main cause of Page kidney is the renal biopsy in the context of kidney transplantation. The treatment is not recommended in the guidelines although the conservative management is proposed as first option.

Riñón de Page: hematoma subcapsular renal e hipertensión arterial. Presentación de un nuevo caso y revisión de la literatura / Page kidney: subcapsular haematoma and arterial hypertension. A new case report and review of the literature

OBJETIVO: se presenta el caso de un hematoma subcapsular renal espontáneo con elevación de las cifras de tensión arterial en un paciente previamente normotenso. MÉTODOS: paciente que acude por dolor abdominal, de aparición espontánea sin antecedente traumático. El TC demuestra la presencia de un hematoma subcapsular renal derecho. En la planta de hospitalización se registran cifras elevadas de tensión arterial. CONCLUSIÓN: el riñón de Page es una causa de hipertensión arterial debida a una compresión extrínseca del parénquima renal. Sin una alta sospecha clínica podría interpretarse como hipertensión arterial esencial. Actualmente la causa más frecuente de este proceso ocurre en relación con la biopsia renal en pacientes trasplantados. El tratamiento no está consensuado en guías clínicas aunque el manejo médico conservador se propone como primera elección (AU)

OBJECTIVE: We present the case of a spontaneous subcapsular renal hematoma with increase of the levels of blood pressure in a patient previously normotensive. METHODS: Patient with abdominal pain, spontaneous without previous trauma. CT showed a right subcapsular kidney hematoma. High levels of blood pressure were noticed at the admission in urology. CONCLUSION: Page kidney is a cause of arterial hypertension due to external compression of renal parenchyma. It could be unnoticed as essential hypertension if high suspicion is not taken into account. Nowadays, the main cause of Page kidney is the renal biopsy in the context of kidney transplantation. The treatment is not recommended in the guidelines although the conservative management is proposed as first option (AU)

Laparoscopic management of right renal angiomyolipoma with involvement of the inferior vena cava: case report and review of the literature.

This article reports the case of a 22-year-old woman with right renal angiomyolipoma (AML) and inferior vena cava thrombus. Laparoscopic right nephrectomy and thrombectomy were performed. To the authors' knowledge there have been only 46 reported cases of renal AML with endovascular extension and this is the first case to be completely removed by a laparoscopic approach. Laparoscopic management of this kind of tumour is feasible in spite of the vascular involvement. The centre's experience and enlargement of the tumour are key points for this approach.

Right renal infarction: a new case report.

OBJECTIVE: To present a new case of renal infarction. METHODS: We report the case of an 84-year-old woman presenting with right flank colic pain of 24 hours of evolution and past history of acute myocardial infarction four months before. CONCLUSION: Renal infarction is a rare condition; in most of the cases it does not show specific symptoms and usually overlap with other more common urologic procedures, which results in a delay in diagnosis and treatment. The most conclusive imaging tests are i.v contrast CT scan or Doppler ultrasound but definitive diagnosis is achieved by angiography or CT angiography. Treatment is conservative, with parenteral and oral anticoagulation; invasive management is rare.

Infarto renal derecho. Presentación de un nuevo caso / Right renal infarction: a new case report

OBJETIVO: Presentar un nuevo caso de infarto renal. MÉTODOS: Se presenta el caso de una mujer de 84 años con dolor cólico en flanco derecho de 24 horas de evolución y con antecedente de infarto agudo de miocardio cuatro meses antes. CONCLUSIÓN: El infarto renal es una patología rara, dando lugar en la mayoría de los casos a una sintomatología inespecífica y solapable a otros procesos urológicos más frecuentes, lo que implica un retraso en su diagnóstico y en su tratamiento. Las pruebas de imagen más concluyentes son la Tc con contraste o la Eco-Doppler pero el diagnóstico de certeza es por angiografía o angio-Tc. Su tratamiento es conservador, anticoagulación parenteral y oral, el manejo invasivo es infrecuente (AU)

OBJECTIVE: To present a new case of renal infarction. METHODS: We report the case of an 84-year-old woman presenting with right flank colic pain of 24 hours of evolution and past history of acute myocardial infarction four months before. CONCLUSION: Renal infarction is a rare condition; in most of the cases it does not show specific symptoms and usually overlap with other more common urologic procedures, which results in a delay in diagnosis and treatment. The most conclusive imaging tests are i.v contrast CT scan or Doppler ultrasound but definitive diagnosis is achieved by angiography or CT angiography. Treatment is conservative, with parenteral and oral anticoagulation; invasive management is rare (AU)

Secondary bladder amyloidosis: a new case report.

OBJECTIVE: To report a new case of secondary bladder amyloidosis, beinginvolvement of the urinary bladder by amyloidosis infrequent on the basis of very few references in the literature (we estimate the number of cases of secondary vesical amyloidosis reported to be around 30). METHODS/RESULTS: The case presented here corresponds to secondary bladder amyloidosis in a patient suffering from Still's disease, who began with hematuria and ended dying. CONCLUSION: Secondary bladder amyloidosis constitutes a very infrequent pathology, and we can distinguish between primary forms of bladder amyloidosis and systemic forms of amyloidosis that affect the urinary bladder (secondary bladder amyloidosis). It is associated in the majority of patients with rheumatoid arthritis that has evolved over a long period. Clinical diagnosis is difficult, and it is necessary to carry out differential diagnosis with bladder tumours. The pathological and immunohistochemical studies confirm the diagnosis.

Un nuevo caso de amiloidosis vesical secundaria / Secondary bladder amyloidosis: a new case report

OBJETIVO: Dar a conocer un nuevo caso de amiloidosis vesical secundaria, siendo la afectación vesical en la amiloidosis un hecho poco frecuente, en base a la escasez de referencias en la literatura (estimamos que el número de casos de amiloidosis vesical secundaria descritos se aproxima a 30). MÉTODO/RESULTADO: El caso que presentamos corresponde a una amiloidosis vesical secundaria en un paciente afecto de Enfermedad de Still, que debutó con hematuria y presentó evolución fatal. CONCLUSIÓN: La amiloidosis vesical secundaria constituye una entidad patológica muy infrecuente, pudiendo distinguir entre formas primarias de amiloidosis vesical y formas de amiloidosis sistémica con afectación vesical (amiloidosis vesical secundaria). Se asocia en la mayor parte de los pacientes a artritis reumatoide de larga evolución. El diagnostico clínico es difícil, siendo necesario el diagnóstico diferencial con los tumores vesicales. El estudio patológico e inmunohistoquímico, confirma el diagnóstico (AU)

OBJECTIVE: To report a new case of secondary bladder amyloidosis, beinginvolvement of the urinary bladder by amyloidosis infrequent on the basis of very few references in the literature (we estimate the number of cases of secondary vesical amyloidosis reported to be around 30). METHODS/RESULTS: The case presented here corresponds to secondary bladder amyloidosis in a patient suffering from Still’s disease, who began with hematuria and ended dying. CONCLUSION: Secondary bladder amyloidosis constitutes a very infrequent pathology, and we can distinguish between primary forms of bladder amyloidosis and systemic forms of amyloidosis that affect the urinary bladder (secondary bladder amyloidosis). It is associated in the majority of patients with rheumatoid arthritis that has evolved over a long period. Clinical diagnosis is difficult, and it is necessary to carry out differential diagnosis with bladder tumours. The pathological and immunohistochemical studies confirm the diagnosis (AU)

Expression of matrix metalloproteinase-9 in prostate cancer. Preliminary experience.

OBJECTIVES: To study the validity of Matrix Metalloproteinase 9 as a complementary marker to PSA for the diagnosis and prognosis of Prostate Cancer. METHODS: Prospective study structured as a hospital-based cohort of 100 consecutive patients undergoing prostate biopsy. Serum determination of MMP-9 was carried out by means of inmunoassay. Statistical analysis was performed using the Stata/SE 8.2 software. RESULTS: 32 patients were diagnosed with prostate cancer and 52% had a Gleason score equal to or greater than 7. The values of serum MMP-9 varied between 225.7 and 1932.3 ng/ml, without significant differences among patients with benign, malignant and uncertain histology (p=0.429). The differences approached statistical significance in the subgroup of patients with PSA at 4-10 ng/ml (p=0.058), and significant differences were observed in the subgroup with free PSA to total PSA coefficient of less than 15% (p=0.037). No relationship between the Gleason score and the level of MMP-9 was shown (p=0.739). The levels of PSA and MMP-9 were shown to be independent (Pearson coefficient of correlation -0.1). CONCLUSIONS: It was not possible to show the efficacy of MMP-9 in predicting the result of the biopsy. In the group of patients with slightly increased levels of PSA (between 4 and 10 ng/ml) all the descriptive variables were higher in the group with malignant histology, though they did not reach statistical significance, they did reach significance when the coefficient of free PSA over total PSA was less than 15%, but this finding is not relevant clinically, as these patients already have a clear indication for biopsy. Neither was the relationship with the prognosis shown as there are no differences of MMP-9 expression at varying Gleason scores.

Expresión de metaloproteasa de matriz 9 en el cáncer de próstata. Experiencia preliminar / Expression of matrix metalloproteinase-9 in prostate cancer. Preliminary experience

OBJETIVO: Estudiar la validez de la metaloproteasa 9 (MMP-9) como marcador complementario al PSA en el diagnóstico y el pronóstico del carcinoma de próstata.MÉTODO: Estudio prospectivo estructurado como cohorte de base hospitalaria. Fueron incluidos 100 pacientes consecutivos a los que se iba a practicar una biopsia prostática. La determinación sérica de MMP-9 se realizó mediante inmunoensayo, y el análisis estadístico con el programa informático stata/SE 8.2.RESULTADOS: 32 pacientes fueron diagnosticados de carcinoma prostático y el 52% de ellos con grado Gleason mayor o igual a 7. Los valores de MMP-9 sérica oscilaron entre 225,7 y 1932,3 nanogramos por mililitro, sin encontrar diferencias estadísticamente significativas entre los pacientes con histología benigna, maligna e incierta (p=0,429). Las diferencias se acercaron a la significación estadística en el subgrupo de pacientes con PSA 4-10 ng/ml (p=0,058) y en el subgrupo PSA libre/total menor de 15% se observaron diferencias significativas (p=0,037). No se encontró relación entre el grado Gleason y el nivel de MMP-9 (p=0,739). Los niveles de PSA y MMP-9 demostraron ser independientes (Coeficiente de correlación de Pearson -0,1).CONCLUSIONES: No fue posible demostrar la eficacia de la MMP-9 para predecir el resultado de la biopsia. En el grupo de pacientes con elevaciones discretas del PSA (entre 4 y 10 ng/ml) todas las variables descriptivas fueron superiores en el grupo con histología maligna, sin alcanzar la significación estadística. Sí se alcanzó la significación cuando el cociente de PSA libre entre PSA total fue menor del 15%, pero este hallazgo no tiene relevancia en la práctica clínica, pues estos pacientes ya tienen indicación clara de biopsia. Tampoco se demuestra relación con el pronóstico al no existir diferencias de expresión de MMP-9 entre diferentes grados Gleason(AU)

OBJECTIVES: To study the validity of Matrix Metalloproteinase 9 as a complementary marker to PSA for the diagnosis and prognosis of Prostate Cancer.METHODS: Prospective study structured as a hospital-based cohort of 100 consecutive patients undergoing prostate biopsy. Serum determination of MMP-9 was carried out by means of inmunoassay . Statistical analysis was performed using the Stata/SE 8.2 software.RESULTS: 32 patients were diagnosed with prostate cancer and 52% had a Gleason score equal to or greater than 7. The values of serum MMP-9 varied between 225.7 and 1932.3 ng/ml, without significant differences among patients with benign, malignant and uncertain histology (p=0.429). The differences approached statistical significance in the subgroup of patients with PSA at 4-10 ng/ml (p=0.058), and significant differences were observed in the subgroup with free PSA to total PSA coefficient of less than 15% (p=0.037). No relationship between the Gleason score and the level of MMP-9 was shown (p=0.739). The levels of PSA and MMP-9 were shown to be independent (Pearson coefficient of correlation -0.1).CONCLUSIONS: It was not possible to show the efficacy of MMP-9 in predicting the result of the biopsy. In the group of patients with slightly increased levels of PSA (between 4 and 10 ng/ml) all the descriptive variables were higher in the group with malignant histology, though they did not reach statistical significance, they did reach significance when the coefficient of free PSA over total PSA was less than 15%, but this finding is not relevant clinically, as these patients already have a clear indication for biopsy. Neither was the relationship with the prognosis shown as there are no differences of MMP-9 expression at varying Gleason scores(AU)