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

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

The American Society of Anesthesiologists Physical Status (ASA-PS) Risk Group Classification Can Be Used to Anticipate Functional Recovery Outcomes after the Surgical Treatment of Female Urinary Incontinence with Transobturator Suburethral Tape.

INTRODUCTION: Stress urinary incontinence (SUI) has an incidence of 15-80% in women. One of the most widely used surgical techniques for treatment is the placement of a suburethral transobturator tape (TOT). Although this technique has a relatively low morbidity rate, it is not exempt from intraoperative or postoperative complications, which can have an impact on functional recovery, understood as the return to routine life prior to the intervention. AIMS: To assess the time for functional recovery in women operated on for SUI by TOT; to identify complications and related factors, according to anaesthetic risk, which condition the time to functional recovery; and proposals for improvements in the prevention of possible complications and in reducing functional recovery time. MATERIALS AND METHODS: A non-concurrent prospective observational multicenter study of 891 women undergoing TOT for stress urinary incontinence since 1 April 2003, who were successful in achieving urinary continence (completely dry). Study groups: GA (n = 443): patients with ASA I risk. GB (n = 306): patients with ASA II risk. GC (n = 142): patients with anaesthetic risk ASA III. Investigated variables: age, body mass index, follow-up time, secondary diagnoses, surgical history, obstetric-gynecological history, toxic habits, and complications derived from surgery: bleeding, pain, infection. Descriptive statistics, Student's t test, Chi2, Fisher, ANOVA, multivariate analysis, significance for p < 0.05. RESULTS: Mean age was 60.10 years (SD13.38), with no difference between groups. Mean body mass index (BMI) was 26.55 kg/m2 (SD 4.51), lowest in GA. GB had more HT (38.6%) than GC (23.23%), more type 2 diabetes (19.83% versus 10.56%), and more respiratory disorders (6.97% versus 2.11%). There were more women with anxiety in GB (19.3%) than in GC (6.33%) (p = 0.0221) and GA (10.51%) (p = 0.0004). There was more hypothyroidism in GB (16.08%) compared to GC (2.11%) and GA (9.07%). There was more history of curettage in GC (11.97%) versus GB (5.63%); and more pelvic surgery in GB (71.31%) and GC (66.9%) compared to GA (32.57%). There were more concomitant treatments with benzodiazepines in GC (27.46%) and GB (28.41%) than in GA (8.86%), and more parapharmacy treatments in GB (17.96%) than in GC (6.33%). Following the operation, 113 patients had some sign or symptom that required medical attention: in GA 48 (10.83%), in GB 49 (16.06%), in GC 16 (13.22%). Mean days until functional recovery in patients with complications: in GA 5.72 (SD2.05); bleeding 3 (SD1), pain 6.40 (SD1.34), and infection 7.33 (SD0.57), with fewer days for bleeding than for pain or infection. GB: 27.96 (SD 28.42), bleeding 3 (SD0), pain 46.69 (SD31.36), infection 10.83 (SD3.90); lowest for patients with bleeding. GC: 9.44 (SD 2.50); for bleeding 7.66 (SD2. 08), pain 10.66 (SD1.15), infection 10 (SD3.46); no differences. Overall, for women with bleeding, the time was 4.16 days (SD1.94); less in GA and GB than in GC. Pain, at 31.33 days (SD 30.70), was the factor that most delayed functional recovery; in GB women, it took longer to return to work due to pain (45.96, SD31.36) compared to GA (6.4, SD 1.34) and GC (10.66, SD1.15). In women with infection, overall mean time was 10.11 days (SD 3.61) with no difference between groups. CONCLUSIONS: Mean time for the return to normal activity in patients who underwent TOT for SUI is 5 days if there are no complications, and 16.91 days if there are any. The ASA-SP risk group classification can be used to anticipate functional outcomes. An ASA-PS risk-based functional recovery forecasting protocol should be adapted, especially ASA II patients who may present with long-term disabling postoperative pain. Preventive management measures are proposed that favour functional recovery.

[Urinary tract lymphoepithelial carcinoma. Report of two cases and bibliographic review.] / Carcinoma linfoepitelial del tracto urinario. Presentación de dos casos y revision de la literatura.

OBJECTIVE: We report two cases of patients diagnosed with lymphoepithelioma-like carcinomas of the urinary tract. We review the literature of this rare entity. The objective is to clarify the clinical and therapeutic characteristics. METHODS: We present a retrospective review of medical records of two patients diagnosed with lymphoepithelioma-like carcinomas, one in the renal pelvis and the other in the bladder. We review the epidemiology, diagnosis and therapeutic alternatives. RESULTS: Case 1: A 74-year-old women with past medical history of left radical nephrectomy and retroperitoneal lymphadenectomy six years before for renal pelvis carcinoma type pure lymphoepithelioma-like, stage pT4R0pN1cM0. She received adjuvant chemotherapy with Cisplatin and Gemcitabine. Five years later, she presented tumor recurrence in the left ureteral meatus, this lesion was resected. The pathology reported a high-grade urothelial carcinoma with marked lymphoid component, stage pT1. At follow-up, one year after the last recurrence, the patient was asymptomatic. In tomography control, no local or distant recurrences were objectified. Case 2: A 82-year-old men with diagnosis of muscleinvasive bladder cancer. The tumor caused right obstructive uropathy without extracapsular, regional or remote extension. We performed a radical cystoprostatectomy with bilateral pelvic lymphadenectomy and urinary diversión type cutaneous transureterostomy. The pathology reported a urothelial bladder carcinoma type mixed lymphoepithelioma-like, stage pT4aR1pN2cM0. At six months follow-up, the patient had liver and spleen lesions and retroperitoneal adenopathic nodes, all suggestive of metastases. He is currently receiving symptomatic treatment of their disease. CONCLUSIONS: We emphasize the clinical importance involved in the diagnosis of this entity. The diagnosis influence the aggressiveness of treatment and disease-specific survival. Therefore, concomitant transitional cell carcinoma defines the prognosis. The role of immunohistochemical staining is fundamental, allowing us to confirm the presence of the epithelial component.

Malignant solitary fibrous kidney tumor with peritoneal disease: a case report.

We report a case of a large malignant solitary fibrous kidney tumor. A complete surgical resection of the primary tumor and peritoneal disease was carried out, and a histological examination confirmed the initial diagnosis. We describe and discuss the characteristics of this rare kidney neoplasm.

[Mullerianosis of the urinary bladder: a rare entity]. / Mullerianosis vesical: una entidad infrecuente.

OBJECTIVES: To report a new case of bladder mullerianosis. METHODS: We present the case of a 30 year old female patient with history of miscarriage, who refers voiding dis-turbances with menstruations. Vaginal ultrasound showed an exophytic bladder lesion, which was confirmed by cistoscopy. Endoscopic resection was indicated. RESULTS: The pathological study of tissues obtained showed mixed glandular structures with predominant tubaric-like type, in association with endometrial- and endocervical-like elements. No evidence of endoscopic relapse after one year of follow-up. CONCLUSIONS: We contribute with a new case of bladder mullerianosis. We emphasize the scarcity of its published reports. We support the option of an endoscopic surgery for these patients.

[Da Vinci robot assisted radical prostatectomy: one year experience at the Hospital Clínico San Carlos]. / Prostatectomía radical asistida por robot Da Vinci: un año de experiencia en el Hospital Clínico San Carlos.

OBJECTIVES: Hospital Clínico San Carlos in Madrid is the first Spanish public centre using the latest surgical technology: the Da Vinci robot. First operation was carried out in our department in October 9th 2006. Since then, numerous changes have happened which enabled us to overcome difficulties, to complete the learning curve. METHODS: Between October 9th 2006 and November 30th 2007 we performed 30 radical prostatectomies with the Da Vinci robot. Mean patient age was 63 years (47-70 years) with an ASA (American society of anesthesia) risk below III in all cases, a Gleason score between 2 and 8 and a PSA < or = 15 (3.5-15). Mean prostatic volume measured by transrectal ultrasound was 36 cc (16-90 cc). RESULTS/CONCLUSIONS: Six trocars and a 15 mm Hg pneumoperitoneum were employed. Mean operative room occupation time was 5.9 hours (4-14 hours). Two cases were converted to open surgery and one to laparoscopy. No major intraoperative complications have happened. In the immediate post-operative period, 2 patients presented plexopathy and arthralgia, 1 infection at the site of one trocar, and 2 haematomas at the site of trocar insertion. Sixteen patients required transfusion (mean 1 red blood cells unit (0-4)). Bladder catheter was retrieved between 5th and 21st post-operative days (mean 11 days). Regarding continence: 10 patients were completely continent or present mild incontinence (0-1 pad) and 5 had moderate incontinence (2-5 pads). Three patients preserve sexual potency, the rest show different grades of dysfunction.

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

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

Carcinoma linfoepitelial del tracto urinario. Presentación de dos casos y revisión de la literatura / Urinary tract lymphoepithelial carcinoma. Report of two cases and bibliographic review

OBJETIVO: Presentar dos casos de pacientes diagnosticados de carcinomas linfoepiteliales del tracto urinario. Realizamos una revisión de la literatura de esta infrecuente entidad, con el fin de aclarar las características clínicas y terapéuticas. MÉTODOS: Revisión retrospectiva de la historia clínica de dos pacientes diagnosticados de carcinomas linfoepiteliales, uno en pelvis renal y el otro en vejiga. RESULTADOS: Caso 1: Mujer de 74 años. Se le realiza una nefrectomía radical izquierda y linfadenectomía retroperitoneal por carcinoma de pelvis renal tipo linfoepitelioma like puro, estadio pT4R0pN1cM0. Recibe quimioterapia adyuvante. A los cinco años presenta recidiva tumoral en el meato ureteral izquierdo que se reseca; es informado como carcinoma uroterial de alto grado, con marcado componente linfoide, estadio pT1. Al año de seguimiento de la recidiva la paciente se encuentra asintomática y sin recaída local ni a distancia. Caso 2: Varón de 82 años diagnosticado de carcinoma vesical infiltrante. Se le realiza una cistoprostatectomía radical con linfadenectomía pélvica y derivación urinaria. El resultado es un carcinoma urotelial de vejiga tipo linfoepitelioma- like puro, estadio pT4aR1pN2cM0. A los seis meses se objetiva la aparición de metástasis de órganos sólidos y ganglionares. Actualmente se encuentra con tratamiento sintomático de su enfermedad. CONCLUSIONES: Destacar la importancia clínica que implica el diagnóstico de esta entidad, ya que puede influir en el tratamiento y la supervivencia específica de la enfermedad, siendo el carcinoma uroterial concomitante el que marque el pronóstico. El papel que desempeñan las tinciones inmunohistoquímicas es fundamental, ya que nos permiten confirmar la presencia del componente epitelial

OBJECTIVE: We report two cases of patients diagnosed with lymphoepithelioma-like carcinomas of the urinary tract. We review the literature of this rare entity. The objective is to clarify the clinical and therapeutic characteristics. METHODS: We present a retrospective review of medical records of two patients diagnosed with lymphoepitheliomalike carcinomas, one in the renal pelvis and the other in the bladder. We review the epidemiology, diagnosis and therapeutic alternatives. RESULTS: Case 1: A 74-year-old women with past medical history of left radical nephrectomy and retroperitoneal lymphadenectomy six years before for renal pelvis carcinoma type pure lymphoepithelioma-like, stage pT4R0pN1cM0. She received adjuvant chemotherapy with Cisplatin and Gemcitabine. Five years later, she presented tumor recurrence in the left ureteral meatus, this lesion was resected. The pathology reported a high-grade urothelial carcinoma with marked lymphoid component, stage pT1. At follow-up, one year after the last recurrence, the patient was asymptomatic. In tomography control, no local or distant recurrences were objectified Case 2: A 82-year-old men with diagnosis of muscleinvasive bladder cancer. The tumor caused right obstructive uropathy without extracapsular, regional or remote extension. We performed a radical cystoprostatectomy with bilateral pelvic lymphadenectomy and urinary diversión type cutaneous transureterostomy. The pathology reported a urothelial bladder carcinoma type mixed lymphoepithelioma-like, stage pT4aR1pN2cM0. At six months follow-up, the patient had liver and spleen lesions and retroperitoneal adenopathic nodes, all suggestive of metastases. He is currently receiving symptomatic treatment of their disease. CONCLUSIONS: We emphasize the clinical importance involved in the diagnosis of this entity. The diagnosis influence the aggressiveness of treatment and disease-specific survival. Therefore, concomitant transitional cell carcinoma defines the prognosis. The role of immunohistochemical staining is fundamental, allowing us to confirm the presence of the epithelial component

[Urodynamic test with self reduction of the cystocele in the diagnosis of lower urinary tract obstruction]. / Test urodinámico de autoreducción del cistocele en el diagnóstico de obstrucción del tracto urinario inferior.

OBJECTIVES: The association of cystocele and urodynamic lower urinary tract obstruction is frequent, occasionally not being possible to rule out intrinsic obstruction of bladder neck and urethra. With the aim to confirm the obstructive character of the cystocele we performed at test consisting in manual reduction of the cystocele by the patient herself, to check if by this simple manoeuvre the urodynamic parameters of obstruction disappear or diminish. METHODS: 24 patients consulting for sensation of vaginal bulge, with a mean age of 66 years, participated in the study. The initial diagnosis of lower urinary tract obstruction and cystocele was obtained after video-urodynamic tests. The urodynamic test with self reduction of the cystocele was based on cystomanometry and voiding pressure-flow tests. The parameters of the study included presence, amplitude and bladder capacity during detrusor involuntary contractions in the cystomanometry; in the voiding pressure/flow test the parameters of the study were the URA as a urethra resistance parameter, the type of obstruction with the Chess classification, and Wmax and W80-W20 as parameters of detrusor contractility. RESULTS: A higher frequency of severe (58.3%) than moderate (41.6%) cystocele was demonstrated. No significant relation with age was demonstrated. The URA significantly diminished (p<0.01) with self reduction: from a median value of 30.5 before to 15.5 H2O cm after reduction. Although it was observed in all grades of cystocele, this reduction was greater in the severe ones. The most frequent type of obstruction was the constrictive (62.5%), over compressive (4.2%), mixed (12.5%) and unobstructed (4.2%). The constrictive obstruction significantly disappeared or diminished after reduction (p < 0.05) to a 45.8% of the cases, the compressive to 0%, the mixed to 4.2% and the nonobstructive to 50%. No significant relationship between these data and grade of cystocele was demonstrated. On the other hand, no significant differences were demonstrated with cystocele self reduction in the other urodynamic parameters (detrusor hyperactivity and contractility, Wmax and W80-W20), neither in their relationship with the grade of cystocele. CONCLUSIONS: This test could be very useful in the diagnosis of lower urinary tract obstruction for its validity and significance, apart from being an easy to perform and reproducible test.

[New technique for the repair of anterior pelvic floor compartment defects using a synthetic implant with biological coverage: approach, fixation and transobturator anchoring]. / Nueva técnica de reparación de los defectos del compartimento anterior mediante implante sintético y cubierta biológica: abordaje, fijación y anclaje transobturador.

UNLABELLED: Transobturator systems for anterior vaginal wall prolapse repair exemplify the current trend in pelvic floor surgery. They may be considered an approach and also a mesh fixation system, in opposition to free mesh cystocele repair where they work by the creation of fibrotic tissue after mesh implant (biological or synthetic). OBJECTIVES: To describe the elements of the Avaulta anterior system, its indications and the surgical technique to implant it and adequately adjust it. METHODS: The operation has five steps: (1) midline vaginal incision and mucosal dissection, (2) Obturator foramen identification, design and performance of 2 superior mini incisions in both the genitofemoral folds, and another two 3 cm below and 1-2 cm lateral to them, (3) Needle introduction and passage through the upper portion of the obturator foramen, parallel to the ischiopubic ramus, and once past needle charging with the arm of the implant, (4) Needle introduction and passage from the inferior incisions vertically through the inferior portion of the obturator foramen, directing the needle with bimanual control to the theoretical localization of the uterine.cervix, with connection and charging of the inferior arm of the mesh. (5) Tension free adjustment of the mesh and closure of the incisions. CONCLUSIONS: (1) It is a reproducible technique that adequately corrects the anterior vaginal compartment defects. (2) The design and technology of Avaulta aims to correct the anterior compartment defects, based on the principles of ideal mesh.

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

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

Mullerianosis vesical: una entidad infrecuente / Mullerianosis of the urinary bladder: a rare entity

OBJETIVO: Descripción de un nuevo caso de mullerianosis vesical.MÉTODO: Presentamos el caso de una paciente mujer de 30 años con antecedentes de aborto, que refiere molestias miccionales coincidiendo con las menstruaciones. Una ecografía vaginal demostró la existencia de lesión exofítica vesical, confirmada posteriormente por cistoscopia. Se indicó resección transuretral.RESULTADOS: En el estudio histopatológico de los tejidos obtenidos se objetivó un componente glandular mixto de tipo predominantemente tubárico, con elementos endometriales y endocervicales asociados. No evidencia de recidiva endoscópica tras un año de seguimiento.CONCLUSIONES: Aportamos un nuevo caso de mullerianosis vesical. Destacamos el escaso número de casos publicados. Defendemos la opción quirúrgica endoscópica en estas pacientes(AU)

OBJECTIVES: To report a new case of bladder mullerianosis.METHOD: We present the case of a 30 year old female patient with history of miscarriage, who refers voiding dis-turbances with menstruations. Vaginal ultrasound showed an exophytic bladder lesion, which was confirmed by cistoscopy. Endoscopic resection was indicated.RESULTS: The pathological study of tissues obtained showed mixed glandular structures with predominant tubaric-like type, in association with endometrial- and endocervical-like elements. No evidence of endoscopic relapse after one year of follow-up.CONCLUSIONS: We contribute with a new case of bladder mullerianosis. We emphasize the scarcity of its pu-blished reports. We support the option of an endoscopic surgery for these patients(AU)

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

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

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

Nueva técnica de reparación de los defectos del compartimento anterior mediante implante sintético y cubierta biológica: abordaje, fijación y anclaje transobturador / New technique for the repair of anterior pelvic floor compartment defects using a synthetic implant with biological coverage: approach, fixation and transobturator anchoring

OBJETIVOS: Describir los elementos que componen el sistema Avaulta anterior, sus indicaciones y la técnica quirúrgica mediante la que se implanta y ajusta adecuadamente. METODOS: El método quirúrgico consta de cinco pasos: 1º) incisión vaginal media y disección de la mucosa vaginal, 2º) Identificación del agujero obturador, diseño y realización de dos mini-incisiones superiores en ambos pliegues genitofemorales y otras dos ubicadas a 3 cm por debajo y a 1-2 cms laterales a las primeras, 3º) Introducción y paso de las agujas, pasando por la parte superior del agujero obturador, paralelas a la rama isquiopubiana y una vez pasada se enhebra la aguja con el «brazo» del implante, 4º) Introducción y paso de las agujas por las mini-incisiones inferiores, pasando por la parte inferior del agujero obturador en sentido vertical y dirigiendo la aguja con control bimanual hacia la teórica localización del cuello uterino, con conexión y enhebrado del brazo inferior de la malla sobre la aguja de punción y 5º) Ajuste sin tensión de la malla y cierre de las incisiones vaginal e inguinales. CONCLUSIONES: 1. Se trata de una técnica reproducible que permite corregir adecuadamente los defectos del compartimento anterior vaginal. 2. El diseño y tecnología de Avaulta pretende corregir los defectos del compartimento anterior, basándose en los principios de la malla ideal (AU)

Transobturator systems for anterior vaginal wall prolapse repair exemplify the current trend in pelvic floor surgery. They may be considered an approach and also a mesh fixation system, in opposition to free mesh cystocele repair where they work by the creation of fibrotic tissue after mesh implant (biological or synthetic). OBJECTIVES: To describe the elements of the Avaulta anterior system, its indications and the surgical technique to implant it and adequately adjust it. METHODS: The operation has five steps: (1) midline vaginal incision and mucosal dissection, (2) Obturator foramen identification, design and performance of 2 superior mini incisions in both the genitofemoral folds, and another two 3 cm below and 1-2 cm lateral to them, (3) Needle introduction and passage through the upper portion of the obturator foramen, parallel to the ischiopubic ramus, and once past needle charging with the arm of the implant, (4) Needle introduction and passage from the inferior incisions vertically through the inferior portion of the obturator foramen, directing the needle with bimanual control to the theoretical localization of the uterine.cervix, with connection and charging of the inferior arm of the mesh. (5) Tension free adjustment of the mesh and closure of the incisions. CONCLUSIONS: (1) It is a reproducible technique that adequately corrects the anterior vaginal compartment defects. (2) The design and technology of Avaulta aims to correct the anterior compartment defects, based on the principles of ideal mesh

Test urodinámico de auto reducción del cistocele en el diagnóstico de obstrucción del tracto urinario inferior / Urodynamic test with self reduction of the cystoocele in the diagnosis of lower urinary tract obstruction

Objetivo: Es frecuente la asociación entre el cistocele y la obstrucción urodinámica del tracto urinario inferior, no pudiendo en ocasiones descartar una obstrucción intrínseca de cuello y uretra. A fin de confirmar el carácter obstructivo del cistocele se ha realizado un test que consiste en la reducción manual del cistocele por parte de la propia paciente, para comprobar si con esta simple maniobra desaparecen o al menos disminuyen los parámetros de obstrucción en el estudio urodinámico. Métodos: Participaron 24 pacientes, con una edad media de 66 años, cuyo motivo de consulta era la sensación de bulto en vagina. El diagnóstico inicial de obstrucción del tracto urinario inferior y de cistocele se realizó mediante videourodinámica. El test urodinámico de autoreducción del cistocele se basó en cistomanometría y test de presión/flujo miccional. Los parámetros urodinámicos estudiados fueron la presencia, amplitud y capacidad vesical en las contracciones involuntarias del detrusor, durante la cistomanometría; en el test presión/flujo miccional fueron estudiados el URA como parámetro de resistencia uretral, el tipo de obstrucción con la clasificación de Chess O’ Damero y parámetros de contractilidad del detrusor: Wmax y W80-W20. Resultados: Se demostró una mayor frecuencia de los cistoceles severos (58.3 %), que los moderados (41,6 %). No se demostró relación significativa con la edad. El URA disminuyó significativamente (p<0.01) con la autoreducción: de una mediana pre de 30.5 disminuyó post a un valor de 15.5cm. H2O. Esta reducción aunque se observó en cualquier grado de cistocele, fue mayor en los cistoceles severos. El tipo de obstrucción más frecuente fue la constrictiva (62.5 %); compresiva (4.2 %), mixta (12.5 %), y no obstrucción (4.2 %). La obstrucción constrictiva desapareció o disminuyó significativamente (p<0.05) postautoreducción, a un 45.8 % de los casos, la compresiva a 0 %, mixta 4.2 % y sin obstrucción 50 %. No se demostró relación significativa entre estos datos y el grado de cistocele. Por otra parte, no se demostraron diferencias significativas con la autoreducción del cistocele, en los otros parámetros urodinámicos (hiperactividad detrusor y contractilidad del detrusor: Wmax y W80-W20), así como su relación con el grado de cistocele. Conclusión: Este test podría ser muy útil en el diagnóstico de obstrucción del tracto urinario inferior por su validez y significación, aparte de la sencillez de realización y facilidad de repetición del estudio (AU)

Objectives: The association of cystocele and urodynamic lower urinary tract obstruction is frequent, occasionally not being possible to rule out intrinsic obstruction of bladder neck and urethra. With the aim to confirm the obstructive character of the cystocele we performed at test consisting in manual reduction of the cystocele by the patient herself, to check if by this simple manoeuvre the urodynamic parameters of obstruction disappear or diminish. Methods: 24 patients consulting for sensation of vaginal bulge, with a mean age of 66 years, participated in the study. The initial diagnosis of lower urinary tract obstruction and cystocele was obtained after video-urodynamic tests. The urodynamic test with self reduction of the cystocele was based on cystomanometry and voiding pressure-flow tests. The parameters of the study included presence, amplitude and bladder capacity during detrusor involuntary contractions in the cystomanometry; in the voiding pressure/flow test the parameters of the study were the URA as a urethra resistance parameter, the type of obstruction with the Chess classification, and Wmax and W80-W20 as parameters of detrusor contractility. Results: A higher frequency of severe (58.3%) than moderate (41.6%) cystocele was demonstrated. No significant relation with age was demonstrated. The URA significantly diminished (p<0.01) with self reduction: from a median value of 30.5 before to 15.5 H2O cm after reduction. Although it was observed in all grades of cystocele, this reduction was greater in the severe ones. The most frequent type of obstruction was the constrictive (62.5%), over compressive (4.2%), mixed (12.5%) and unobstructed (4.2%). The constrictive obstruction significantly disappeared or diminished after reduction (p < 0.05) to a 45.8% of the cases, the compressive to 0%, the mixed to 4.2% and the nonobstructive to 50%. No significant relationship between these data and grade of cystocele was demonstrated. On the other hand, no significant differences were demonstrated with cystocele self reduction in the other urodynamic parameters (detrusor hyperactivity and contractility, Wmax and W80-W20), neither in their relationship with the grade of cystocele. Conclusions: This test could be very useful in the diagnosis of lower urinary tract obstruction for its validity and significance, apart from being an easy to perform and reproducible test (AU)

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

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

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