Estenosis de la anastomosis ureteroileal en derivaciones urinarias realizadas mediante abordaje abierto, laparoscópico y robótico. Incidencia y manejo en un centro de tercer nivel / Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center

Introducción Las estenosis de anastomosis ureteroileal son complicaciones frecuentes en conductos ileales y neovejigas ortotópicas. Analizamos su incidencia en función del tipo de derivación urinaria y del abordaje quirúrgico (abierto, laparoscópico o robótico). Describimos su manejo y los resultados obtenidos.Material y métodos Estudio retrospectivo descriptivo durante 6 años en pacientes con derivación urinaria empleando íleon (conducto ileal o neovejiga ileal). Se recogen datos demográficos, comorbilidades, datos quirúrgicos (abordaje, complicaciones) y resultados. Seguimiento mínimo de un año. Comparación entre grupos, mediante test de la chi al cuadrado en variables dicotómicas. Variables cuantitativas comparadas empleando la prueba de la t Student para grupos independientes o la prueba de Mann-Whitney. Consideramos significación estadística p<0,05.Resultados Incluimos a 182 pacientes (84% varones y 16% mujeres). Edad media 68 años. Abordaje de cistectomía: laparoscópica (67/37%), robótica (63/35%), abierta (43/24%). Tipo de derivación: conducto ileal (138/76%) y neovejiga ileal ortotópica (44/24%). Tipo de reimplante: Bricker (108/59%) y Wallace (47/26%). Estenosis de anastomosis ureteroileal (50/27%): bilateral (26), izquierda (16) y derecha (8). Estenosis según abordaje de cistectomía: laparoscópica (23/46%), robótica (16/32%), abierta (9/18%). Tratamiento de estenosis (33/18%): reimplante ureteroileal (13), nefrostomía permanente (13), dilatación endoscópica (4), nefroureterectomía (2), endoureterotomía (1). Abordaje del reimplante: laparoscópico (5/38%), robótico (6/46%) y abierto (2/15%). Resultados tras reimplantes: reestenosis (0/0%), reintervención (3/23%), estenosis ureteroileal contralateral posterior (1/8%).ConclusiónEl tipo de abordaje empleado en la cistectomía no parece influir en la aparición de estenosis ureteroileales. Abordajes laparoscópicos y robóticos permiten su reparación con resultados

Introduction Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes.Material and methodsDescriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t test for independent groups or Mann-Whitney test. Statistical significance if P<.05.Results The study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Ureteric reimplantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%).Conclusion Surgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates (AU)

Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center.

INTRODUCTION: Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes. MATERIAL AND METHODS: Descriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t-test for independent groups or Mann-Whitney test. Statistical significance if P < .05. RESULTS: The study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Uretericre implantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%). CONCLUSION: Surgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates.

Ureteroileal anastomosis stricture after urinary diversions performed by open, laparoscopic and robotic approaches. Incidence and management in a tertiary care center. / Estenosis de la anastomosis ureteroileal en derivaciones urinarias realizadas mediante abordaje abierto, laparoscópico y robótico. Incidencia y manejo en un centro de tercer nivel.

INTRODUCTION: Ureteroileal anastomosis stricture is a frequent complication after radical cystectomy and ileal conduit or orthotopic neobladder formation. We analyze their incidence based on the technique for urinary diversion and on the surgical approach (open, laparoscopic or robot-assisted). Stricture management is described, along with surgical outcomes. MATERIAL AND METHODS: Descriptive retrospective study over 6 years in patients who underwent urinary diversion using ileum (ileal conduit or orthotopic neobladder). Demographic data, comorbidities, surgical approach, complications, and outcomes were collected. Minimum follow-up of 1 year. Comparison between groups using Chi-square test for dichotomous variables. Quantitative variables were compared using the Student's t test for independent groups or Mann-Whitney test. Statistical significance if P<.05. RESULTS: The study included 182 patients (84% males and 16% females). Mean age 68 years. Cystectomy approach: laparoscopic (67/37%), robot-assisted (63/35%), open (43/24%). Urinary diversion: ileal conduit (138/76%) and orthotopic ileal neobladder (44/24%). Ureteric reimplantation technique: Bricker (108/59%) and Wallace (47/26%). Ureteroileal anastomosis strictures (50/27%): bilateral (26), left (16) and right (8). Strictures according to cystectomy approach: laparoscopic (23/46%), robot-assisted (16/32%), open (9/18%). Treatment of strictures (33/18%): ureteric reimplantation (13), indwelling nephrostomy (13), endoscopic dilatation (4), nephroureterectomy (2), endoureterotomy (1). Ureteroileal reimplantation approach: laparoscopic (5/38%), robot-assisted (6/46%), open (2/15%). Outcomes after reimplantation: restenosis (0/0%), reintervention (3/23%), contralateral ureteroileal stricture (1/8%). CONCLUSION: Surgical approach in cystectomy does not influence future development of ureteroileal strictures. Laparoscopic and robot-assisted ureteroileal reimplantation achieves high success rates.

Radiofrecuencia percutánea en el tratamiento de masas renales pequeñas: análisis de resultados y complicaciones tras diez años de experiencia / Percutaneous radiofrequency for the treatment of small renal masses: Analysis of outcomes and complications after 10 years of experience

Introducción y objetivo: El manejo de tumoraciones renales ≤ 4 cm en población anciana o con comorbilidades supone un reto, constituyendo las terapias ablativas una alternativa interesante. El objetivo es evaluar la radiofrecuencia percutánea en el tratamiento de masas renales pequeñas en nuestro centro, las complicaciones asociadas y los resultados obtenidos.Material y métodosEvaluación retrospectiva de las radiofrecuencias realizadas entre abril de 2010 y abril de 2020 en nuestro centro. Se revisaron datos demográficos, comorbilidades asociadas, características tumorales, complicaciones y resultados oncológicos y funcionales.ResultadosSe trataron 57 tumores en 53 pacientes. Seguimiento medio de 48,2 meses. Se obtuvo un 89,5% de ablaciones completas. Hubo un 19,3% de complicaciones. Fueron catalogadas como mayores un 3,5% y un 5,3% según Clavien-Dindo y SIR. Se encontró asociación estadísticamente significativa entre el resultado inicial de la ablación y la edad (p = 0,047), el score RENAL modificado (RENAL-m) (p = 0,044), la presencia de componente quístico (p = 0,049) y el tamaño tumoral (p = 0,01). El punto de corte de tamaño quedó establecido en 25 mm (p = 0,012). En el análisis multivariante, únicamente el tamaño permaneció como predictor de resultado inicial de ablación (p = 0,01; OR 1,183; IC 95% 1,041-1,345). La supervivencia cáncer específica y supervivencia libre de recurrencia a cinco años fueron del 98,1% y del 89,5% respectivamente.Se observó una disminución media del MDRD-4 de 6,59 mL/min (p = 0,005) en los seis primeros meses tras radiofrecuencia (RFA).ConclusionesDados los excelentes resultados oncológicos y funcionales demostrados, la radiofrecuencia percutánea guiada por ecografía es una terapia eficaz y segura en el tratamiento de masas renales pequeñas en pacientes seleccionados. (AU)

Introduction and objective: The management of renal tumors ≤ 4 cm in elderly population or patients with comorbidities is a challenge, for which ablative therapies are an interesting alternative. The objective is to evaluate in our center the role of percutaneous radiofrequency in the treatment of small renal masses, the associated complications and the results obtained.Material and methodsRetrospective evaluation of the radiofrequency treatments carried out between April 2010 and April 2020 in our center. Demographic data, associated comorbidities, tumor characteristics, complications and oncological and functional outcomes were reviewed.ResultsFifty-seven tumors were treated in 53 patients. Mean follow-up of 48.2 months. The percentage of complete ablations obtained was of 89.5%. There were 19.3% of complications. According to Clavien-Dindo and SIR classification systems, 3.5% and 5.3% were major complications. A statistically significant association was found between the initial result of ablation and age (p = 0.047), RENAL-m (p = 0.044), the presence of cystic component (p = 0.049) and tumor size (p = 0.01). The cut-off point for size was established at 25 mm (p = 0.012). In multivariate analysis, only size remained as a predictor of initial ablation result (p = 0.01; OR 1.183; CI 95% 1.041-1.345). Cancer-specific survival and 5-year recurrence-free survival were 98.1% and 89.5%, respectively.A mean decrease of MDRD-4 of 6.59 mL/min (p = 0.005) was observed in the first six months after RFA.ConclusionsGiven the excellent oncological and functional results demonstrated, ultrasound-guided percutaneous radiofrequency ablation is an effective and safe treatment for small renal masses in selected patients. (AU)

Percutaneous radiofrequency for the treatment of small renal masses: Analysis of outcomes and complications after 10 years of experience. / Radiofrecuencia percutánea en el tratamiento de masas renales pequeñas: análisis de resultados y complicaciones tras diez años de experiencia.

INTRODUCTION AND OBJECTIVE: The management of renal tumors ≤ 4 cm in elderly population or patients with comorbidities is a challenge, for which ablative therapies are an interesting alternative. The objective is to evaluate in our center the role of percutaneous radiofrequency in the treatment of small renal masses, the associated complications and the results obtained. MATERIAL AND METHODS: Retrospective evaluation of the radiofrequency treatments carried out between April 2010 and April 2020 in our center. Demographic data, associated comorbidities, tumor characteristics, complications and oncological and functional outcomes were reviewed. RESULTS: Fifty-seven tumors were treated in 53 patients. Mean follow-up of 48.2 months. The percentage of complete ablations obtained was of 89.5%. There were 19.3% of complications. According to Clavien-Dindo and SIR classification systems, 3.5% and 5.3% were major complications. A statistically significant association was found between the initial result of ablation and age (p = 0.047), RENAL-m (p = 0.044), the presence of cystic component (p = 0.049) and tumor size (p = 0.01). The cut-off point for size was established at 25 mm (p = 0.012). In multivariate analysis, only size remained as a predictor of initial ablation result (p = 0.01; OR 1.183; CI 95% 1.041-1.345). Cancer-specific survival and 5-year recurrence-free survival were 98.1% and 89.5%, respectively. A mean decrease of MDRD-4 of 6.59 mL/min (p = 0.005) was observed in the first six months after RFA. CONCLUSIONS: Given the excellent oncological and functional results demonstrated, ultrasound-guided percutaneous radiofrequency ablation is an effective and safe treatment for small renal masses in selected patients.

[Renal graft outcome in patients with combined heart-kidney transplantation]. / Trasplante cardio-renal. Evolucion del injerto renal.

INTRODUCTION: Improvement in surgical and organ preservation techniques and immunosuppressive therapy has permitted multiorganic transplants in patients needing both heart and kidney organs in a synchronous or asynchronous way. OBJECTIVES: To review our results in renal transplants in those patients with both heart and kidney transplants. MATERIAL AND METHOD: Retrospective study of the 7 patients with heart and kidney transplants performed in our Hospital. We have reviewed patients main characteristics, heart and renal failure causes, renal graft and patient outcome and complications related to renal transplant. RESULTS: Between 1985 and 2006 we performed 411 heart transplants; in 7 out of those 411 patients (1.7%) we performed 9 renal transplants, 2 simultaneously and 7 non-simultaneously. All patients were male; their average age at heart transplant was 51.3+/-12.2 years (24-60); the causes of the heart transplant were dilated myocardiopathy in 4 cases (57.2%), rheumatic cardiopathy in 1 (14.3%) and ischemic cardiopathy in 2 (28.5%). The average age at renal transplant was 57.5+/-11.2 years (32-68); the causes of the end renal failure were cyclosporine nephrotoxicity in 3 cases (33.3%), nephroangiosclerosis in 1 (11.1%), chronic interstitial nephropathy in 2 (22.2%), membranoproliferative glomerulonephritis in 1 (11.1%) and chronic rejection in 2 (22.2%). In the 2 simultaneous heart-kidney transplants cold ischemia was 4 hours long, immediate diuresis was seen in 1 case (50%) and there were no complications related to the kidney transplants. The time between the heart and kidney transplants in the 7 non-simultaneous heart-kidney transplants was 105.9+/-51.8 months (23-201 months), cold ischemia was 20.3+/-1.5 hours (18-22) and there was immediate diuresis in 5 cases (71.5%); 2 patients had no complications, 2 cases had acute renal rejection episodes, 1 case of perirenal haematoma, 1 renal polar infarction, lymphocele, 1 case of wound infection, 1 urinary infection and 2 pulmonary infections. Medium follow-up is 52.2+/-33.9 months (12-93); all patients are alive with functioning grafts with creatinine level of 1.8+/-0.43 mg/100 (1.4-2.4). Two renal grafts were lost due to chronic rejection 138 and 270 days after the kidney transplants. The immunotherapy was based on mycophenolate mofetil acid and tacrolimus, though it varied. CONCLUSIONS: The final renal failure associated to cardiopathies needing or having needed heart transplant does not preclude the transplants of both organs.

[Performance of antibiotic prophylaxis in our Urologic Department]. / Cumplimiento de profilaxis antibiótica en un Servicio de Urología.

INTRODUCTION: The rate of surgical site infection is a good indicator of the quality of care in surgical departments. Antibiotic prophylaxis represents a measure of proven efficiency in preventing the infection in a surgical site, and its fulfilment is a main goal in management contracts of health services. The efficiency of this preventive measure requires the existence of updated protocols and performance evaluation. OBJECTIVE: To evaluate the compliance of this antibiotic protocol in our Urology Department with the global analysis of the causes of inadequate prophylaxis and by procedures. MATERIAL AND METHODS: The Department of Preventive Medicine as an outside observer, through a retrospective study, analyzed 695 urological surgical procedures (inpatient and outpatient) during the years 2003 and 2006 for its annual assessment of compliance with the antibiotic prophylaxis protocol. Administration of non-indicated prophylaxis, non-administration of indicated prophylaxis and incorrect dosage are considered as inappropriate prophylaxis. RESULTS: The compliance of the protocol was appropriate in 83.16% of the operations. The cause of the most frequent inadequacy was an incorrect pattern in 15.3%. Within this incorrect pattern the main reason was the delay of administration of prophylactic antibiotic and to a lesser extent an incorrect length of the antibiotic regime. CONCLUSIONS: The percentage of compliance with the antibiotic protocol in our Urology Department is high. The evaluation detected two problems of a different nature and solution: to adapt the timing of antibiotics is a functional, structural and organizational problem to be resolved in accordance with the Anaesthesiology Department. The number of doses of antibiotics in open prostate surgery requires knowledge and strict adherence to the guidelines by the surgeons. The efficiency of antibiotic prophylaxis requires the existence of appropriated and updated protocols for the unifications of criteria among professionals to detect new problems as well as to find solutions for its adequate compliance.

Seminoma en paciente con Síndrome de Kartagener / Testicular seminoma in a patient with Kartagener's syndrome

Objetivo: Presentar la asociación de seminoma en paciente afecto de SK y su relación con la fertilidad. Métodos: Se describe la presencia de un seminoma en paciente afecto de SK, haciendo hincapié en la posible correlación de ambas patologías con la fertilidad, así como se comentan citas bibliográficas de interés. Resultado: Paciente con tumor testicular y SK al que se realizó orquiectomía, resultando ser un seminoma en el estudio anatomopatológico. Se realizaron dos espermiogramas en los que se corroboró la azoospermia, siendo difícil de diferenciar la posible implicación de ambas patologías en relación con la ausencia de espermatozoides en el eyaculado. Conclusiones: Presentamos un caso de seminoma en paciente afecto de SK y azoopermia. Tras la orquiectomía la evolución es favorable, haciéndose breve referencia bibliográfica al SK y sus potenciales implicaciones en la fertilidad. La asociación de este síndrome con tumor testicular es excepcional en la bibliografía consultada (AU)

Objective: To present the association between Seminoma and Kartagener's Syndrome (KS), and its relation with infertility. Methods: We report one case of Seminoma in a patient with Kartagener's Syndrome, focussing on the possible relation between both pathologies and fertility. Bibliographic references are discussed. Results: Orchyectomy was performed on a patient with Kartagener's Syndrome and testicular tumour. The pathology result was Seminoma. Azoospermia was obtained twice in the postoperative espermiogram, not being easy to establish the implication of each pathology (KS or Seminoma) in infertility. Conclusions: A patient with KS and Seminoma plus azoospermia is reported, with a great outcome from the oncological point of view. Bibliographic references are described. The association between KS and Seminoma is exceptional in the literature (AU)

Trasplante cardio-renal. Evolucion del injerto renal / Renal graft outcome in patients with combined heart-kidney transplantation

Introducción: La mejora en las técnicas de conservación de órganos, quirúrgicas y en el tratamiento inmunosupresor ha permitido que los pacientes necesitados de un segundo órgano sean incluidos en lista de espera para trasplante bien sincrónico o asincrónico. Objetivos: Revisión de los resultados obtenidos en el trasplante renal (TxR) en pacientes con trasplante cardíaco (TxC) bien de forma sincrónica o asincrónica. Material y métodos: Estudio retrospectivo de los pacientes con TxC y TxR realizados en nuestro Hospital. Se revisaron las características de los pacientes, causa del fallo cardíaco y renal, evolución del injerto renal y paciente así como las complicaciones del TxR. Resultados: Entre 1985 y 2006 realizamos 411 TxC, en 7 de estos pacientes (1,7%) realizamos 9 TxR, 2 sincrónicos y 7 asincrónicos. Los 7 pacientes eran varones con una edad media al TxC de 51,3±12,2 años (24-60); la causa del TxC fue miocardiopatía dilatada en 4(57,2%), cardiopatía reumática en 1 (14,3%) y cardiopatía isquémica en 2 (28,5%). La edad al TxR fue 57,5±11,2 años (32-68); la causa de insuficiencia renal fue nefrotoxicidad por ciclosporina en 3 (33,3%), nefroangioesclerosis en 1 (11,1%), nefropatía intersticial crónica en 2 (22,2%), glomerulonefritis membranoproliferativa en 1 (11,1%) y nefropatía crónica del injerto en 2 (22,2%). Hubo 2 Tx sincrónicos en los cuales la isquemia fría renal fue de 4 horas, en 1 (50%) hubo diuresis inmediata; no hubo ninguna complicación relacionada con el injerto renal. En los 7 asincrónicos el tiempo entre el TxC y TxR fue de 105,9±51.8meses (23 y 201 meses); la isquemia fría renal fue 20,3±1,5 horas (18-22); hubo diuresis inmediata en 5 de ellos (71,5%). En 2 de ellos no hubo complicaciones, hubo 2 casos de rechazo agudo, 1 hematoma perirrenal, 1 infarto polar, 1 linfocele, 1 infección de herida, 1 infección de orina y 2 infecciones respiratorias. El seguimiento medio es de 52,2±33,9 meses (12-93); todos los pacientes viven con injerto funcionante con cifras de creatinina de 1,8±0,43 mg/100 (1,4-2,4). Los 2 injertos que se perdieron fue por nefropatía crónica del injerto a los 138 y 270 días. La pauta de inmunosupresión fue variable, siendo la asociación de micofenolato y tacrolimus con o sin esteroides la más repetida. Conclusiones: El fracaso renal crónico asociado a cardiopatías que precisen o hayan precisado TxC no excluye el trasplante de ambos órganos (AU)

Introduction: Improvement in surgical and organ preservation techniques and immunosuppressive therapy has permitted multiorganic transplants in patients needing both heart and kidney organs in a synchronous or asynchronous way. Objectives: To review our results in renal transplants in those patients with both heart and kidney transplants. Material and method: Retrospective study of the 7 patients with heart and kidney transplants performed in our Hospital. We have reviewed patients´ main characteristics, heart and renal failure causes, renal graft and patient outcome and complications related to renal transplant. Results: Between 1985 and 2006 we performed 411 heart transplants; in 7 out of those 411 patients (1.7%) we performed 9 renal transplants, 2 simultaneously and 7 non-simultaneously. All patients were male; their average age at heart transplant was 51.3±12.2 years(24-60); the causes of the heart transplant were dilated myocardiopathy in 4 cases (57.2%), rheumatic cardiopathy in 1 (14.3%) and ischemic cardiopathy in 2 (28.5%).The average age at renal transplant was 57.5±11.2 years (32-68); the causes of the end renal failure were cyclosporine nephrotoxicityin 3 cases (33.3%), nephroangiosclerosis in 1 (11.1%), chronic interstitial nephropathy in 2 (22.2%), membranoproliferative glomerulonephritis in 1 (11.1%) and chronic rejection in 2 (22.2%).In the 2 simultaneous heart-kidney transplants cold ischemia was 4 hours long, immediate diuresis was seen in 1 case (50%) and there were no complications related to the kidney transplants. The time between the heart and kidney transplants in the 7 non-simultaneous heart-kidney transplants was 105.9±51.8 months (23-201 months), cold ischemia was 20.3±1.5 hours (18-22) and there was immediate diuresis in 5 cases (71.5%); 2 patients had no complications,2 cases had acute renal rejection episodes, 1 case of perirenal haematoma, 1 renal polar infarction, 1 lymphocele, 1 case of wound infection, 1 urinary infection and 2 pulmonary infections. Medium follow-up is 52.2±33.9 months (12-93); all patients are alive with functioning grafts with creatinine level of 1.8±0.43 mg/100(1.4-2.4). Two renal grafts were lost due to chronic rejection 138 and 270 days after the kidney transplants. The immunotherapy was based on mycophenolate mofetil acid and tacrolimus, though it varied. Conclusions: The final renal failure associated to cardiopathies needing or having needed heart transplant does not preclude the transplants of both organs (AU)

Cumplimiento de profilaxis antibiótica en un Servicio de Urología / Performance of antibiotic prophylaxis in our urologic department

Introducción: La tasa de infección del sitio quirúrgico es un buen indicador de la calidad asistencial en los servicios quirúrgicos. La profilaxis antibiótica representa una medida de eficacia probada en la prevención de la infección del sitio quirúrgico y su cumplimiento constituye un objetivo en los contratos de gestión de los servicios de salud. La eficacia de esta medida preventiva requiere la existencia de protocolos de actuación actualizados y la evaluación de los mismos. Objetivo: Evaluar el cumplimiento de ese protocolo antibiótico en nuestro Servicio analizando las causas de profilaxis inadecuada de forma global y por procedimientos. Material y métodos: El servicio de Medicina Preventiva, como observador externo, por medio de un estudio retrospectivo analizó 695intervenciones quirúrgicas (en pacientes ingresados y ambulantes) realizadas por el servicio de Urología durante los años 2003 al 2006 para su evaluación anual del cumplimiento del protocolo de profilaxis antibiótica. Se considera profilaxis inadecuada la administrada no estando indicada, la no administrada estando indicada y la administrada con pauta incorrecta. Resultados: El cumplimiento del protocolo es adecuado en el 83,16% de las intervenciones. La causa de inadecuación más frecuente fue la pauta incorrecta en el 15,3 %. Dentro de esta pauta incorrecta la causa principal fue el momento de administración tardío del antibiótico profiláctico y en menor medida una duración incorrecta de la pauta antibiótica. Conclusiones: El porcentaje de cumplimento del protocolo antibiótico en nuestro servicio de Urología es alto. La evaluación detectó dos problemas de diferente índole y solución: El adecuar el momento de administración del antibiótico es un problema funcional, estructural y organizativo a resolver junto al servicio de Anestesiología; El número de dosis de antibiótico en cirugía abierta de próstata requiere el conocimiento y cumplimiento estricto de la pauta por parte de los cirujanos La efectividad de la profilaxis antibiótica requiere la existencia de protocolos adecuados y actualizados para la unificación de criterios entre los profesionales, para detectar nuevos problemas, así como para buscar soluciones para un correcto cumplimiento del mismo (AU)

Introduction: The rate of surgical site infection is a good indicator of the quality of care in surgical departments. Antibiotic prophylaxis represents a measure of proven efficiency in preventing the infection in a surgical site, and its fulfilment is a main goal in management contracts of health services. The efficiency of this preventive measure requires the existence of updated protocols and performance evaluation. Objective: To evaluate the compliance of this antibiotic protocol in our Urology Department with the global analysis of the causes of inadequate prophylaxis and by procedures. Matherial and Methods: The Department of Preventive Medicine as an outside observer, through a retrospective study, analyzed 695urological surgical procedures (inpatient and outpatient) during the years 2003 and 2006 for its annual assessment of compliance with the antibiotic prophylaxis protocol. Administration of non-indicated prophylaxis, non-administration of indicated prophylaxis and incorrect dosage are considered as inappropriate prophylaxis. Results: The compliance of the protocol was appropriate in 83.16% of the operations. The cause of the most frequent inadequacy was an incorrect pattern in 15.3%. Within this incorrect pattern the main reason was the delay of administration of prophylactic antibiotic and to a lesser extent an incorrect length of the antibiotic regime. Conclusions: The percentage of compliance with the antibiotic protocol in our Urology Department is high. The evaluation detected two problems of a different nature and solution: to adapt the timing of antibiotics is a functional, structural and organizational problem to be resolved in accordance with the Anaesthesiology Department. The number of doses of antibiotics in open prostate surgery requires knowledge and strict adherence to the guidelines by the surgeons. The efficiency of antibiotic prophylaxis requires the existence of appropriated and updated protocols for the unifications of criteria among professionals to detect new problems as well as to find solutions for its adequate compliance (AU)

Evolución del injerto renal en los pacientes con trasplante hepático asociado / Renal graft outcome in patients with associated liver transplant

Introducción: Casi el 50% de los receptores de trasplante hepático (TxH) tienen asociada un insuficiencia renal (IR) en diverso grado, a su vez, los pacientes en hemodiálisis tienen mayor riesgo de desarrollar procesos hepáticos en relación con infecciones víricas o patologías concomitantes. La mejora en las técnicas de conservación de órganos, quirúrgicas y en el tratamiento inmunosupresor ha permitido que los pacientes necesitados de un segundo órgano sean incluidos en lista de espera para trasplante bien sincrónico o asincrónico. Objetivos: Revisión de los resultados obtenidos en el trasplante renal (TxR) en pacientes que tienen asociado un TxH de forma sincrónica o asincrónica. Material y métodos: Estudio retrospectivo de los pacientes con TxH y TxR realizados en nuestro Hospital. Se revisaron las características de los pacientes, causa de fallo hepático y renal, evolución del paciente y del injerto renal y las complicaciones en relación con el injerto renal. Resultados: Desde 1975 hemos realizado 1483 TxR y 409 TxH desde 1991, se hicieron 17 TxR en 15 de estos pacientes (3,7%). 4 pacientes eran mujeres (26,7%) y 11 varones (73,3%). La edad al TxH fue 52,5±9,3 años (entre 37 y 61 años) siendo las causas de fracaso hepático cirrosis enólica en 10 pacientes, hepatoma en 3 y hepatopatía vírica en 2. El TxR se hizo a una edad de 51±12.5 años (35 y 66 años). La causa de fallo renal fue glomerulonefritis crónica en 6 casos, nefropatía diabética en 3, nefropatía hipertensiva en 1, poliquistosis renal en 1 y no filiada en 4. La isquemia fría fue de 20,5±5,4 horas (8-27 horas) en los asincrónicos y 6,4±5,4 en los sincrónicos (6-8 horas). Tres pacientes tenían TxR previo al hepático, 2 funcionantes sin que el TxH les afectase, y otro le había perdido por recidiva de glomerulonefritis IgA recibiendo un TxH y TxR sincrónico. La causa del fallo hepático en los 3 casos fueron hepatomas en relación con hepatopatías víricas B y C. En 6 casos se hizo Tx simultáneo y en 8 el Tx renal se hizo entre 16 y 83 meses tras el TxH (x=50,5±25,9 meses). Hubo diuresis inmediata en 3 de los sincrónicos (50%) y 3 de los asincrónicos (17,7%). Se perdió un injerto renal por trombosis venosa a las 24horas y otros 2 por recidiva de la enfermedad (1 caso previo al TxH). El resto eran injertos funcionantes entre 4 y 264 meses de seguimiento (x=92,5±66,7 meses) con una creatinina media de 1,86±9,48 mg/100 oscilando entre 1 y 4,5. Han fallecido 5 pacientes, 4 por fracaso del injerto hepático con riñón funcionante a los 8 y 11 meses y 7 y 21 años con cifras de creatinina respectivamente de 3, 4,5, 1,1 y 1,1; otro paciente falleció a los 14 años por cáncer de esófago con creatinina de 1,16. Complicaciones en los casos asincrónicos fueron 5 rechazos agudos, 3 necrosis tubulares, 1 infección de herida, 1 hematoma perirrenal, 2 estenosis ureterales, 1 embolismo arterial en pierna derecha. En los casos sincrónicos no hubo casos de rechazo agudo, 2 necrosis tubulares, 1 trombosis venosa, 2 infecciones de herida, 1 hematoma perirenal y 1 fístula urinaria. La inmunosupresión fue variable siendo las asociaciones más frecuentes esteroides más tacrolimus en 7 (en tres casos tenían además micofenolato) y esteroides más ciclosporina en 3 (en 1 caso más micofenolato). Conclusiones: El trasplante hepatorenal es una alternativa válida en los pacientes con insuficiencia hepática y renal terminal. La incidencia derechazo agudo es parece menor en los casos sincrónicos (AU)

Introduction: Nearly 50% of liver transplant recipients have some degree of renal failure; patients in haemodialysis treatment have a higher risk of suffering hepatic diseases related to viral infections or concomitant pathologies. Improvement in surgical and organ preservation techniques and immunosuppressive therapy has permitted multiorganic transplants in patients needing both liver and kidney organs. Objectives: To review our results in renal transplants in those patients with liver and kidney transplants. Material and method: Retrospective study of the 15 patients with liver and kidney transplants performed in our Hospital. We have reviewed patients´ main characteristics, liver and renal failure causes, renal graft and patient outcome and complications relate to renal transplant. Results: Between 1975 and December 2006 we performed 1483 kidney transplants and between 1991 and December 2006, 409 liver transplants. We performed multiorganic liver and kidney transplants to 15 patients (4 women and 11 men). The average for liver transplant recipients was 52.5±9.3 years (range 37-61) and for kidney transplant recipients was 51±12.5 years (35-66). Cold ischemia was 6.4±5.4 hours (6-8) in simultaneous liver-kidney transplant and 20.5±5.4 (8-27 hours) in non-simultaneous ones. Three patients had a renal transplant before the liver one (two functioning which had no changes after hepatic transplant but the other was lost due to IgA glomeruloneprhitis relapse and received a simultaneous kidney-liver transplant). Six patients received a simultaneous kidney-liver transplant and eight patients a renal transplant between 16 and 83months (x=50.5±25.9 months) after the liver transplant. A renal graft was lost due to renal vein thrombosis and two due to IgA relapse; the others were functioning between 6 and 264 months of follow-up (x=92.5±66.7) with creatinine levels of 1.86±mg/100, (range 1-4.5). Four patients died due to hepatic failure between 8 months and 21 years after renal transplant and another died of oesophagus cancer 14 years after the kidney transplant, in all cases with functioning renal graft. There were no cases of kidney graft acute rejection in simultaneous transplants but there were five in non-simultaneous ones. Immunotherapy was based on steroids and tacrolimus. Conclusions: Liver-kidney transplants are worthy options in patients with hepatic and renal end failure. Acute rejection seems to have fewer incidences in simultaneous liver-kidney transplantation (AU)