Outcomes of an enhanced recovery after radical cystectomy program in a prospective multicenter study: compliance and key components for success.

OBJECTIVE: To investigate the effect of an Enhanced Recovery After Surgery (ERAS) program on complications and length of stay (LOS) after radical cystectomy (RC) and to assess if the number and type of components of ERAS play a key role on the decrease of surgical morbidity. MATERIALS AND METHODS: We analyzed the data of 277 patients prospectively recruited in 11 hospitals undergoing RC initially managed according to local practice (Group I) and later within an ERAS program (Group II). Two main outcomes were defined: 90-day complications rate and LOS. As secondary variables we studied 90-day mortality, 30-day readmission and transfusion rate. RESULTS: Patients in Group II had a higher use of ERAS measures (98.6%) than those in Group I (78.2%) (p < 0.05). Patients in Groups I and II experienced similar complications (70.5% vs. 66%, p = 0.42). LOS was not different between Groups I and II (12.5 and 14 days, respectively, p = 0.59). The risk of having any complication decreases for patients having more than 15 ERAS measures adopted [RR = 0.815; 95% confidence interval (CI) 0.667-0.996; p = 0.045]. Avoidance of transfusion and nasogastric tube, prevention of ileus, early ambulation and a fast uptake of a regular diet are independently associated with the absence of complications. CONCLUSIONS: Complications and LOS after RC were not modified by the introduction of an ERAS program. We hypothesize that at least 15 measures should be applied to maximize the benefit of ERAS.

Robotic sacrocolpopexy for the treatment of pelvic organ prolapse in elderly women: comparative analysis of safety and efficacy versus younger women.

INTRODUCTION: Pelvic organ prolapse is a condition with high prevalence in elderly women. With increasing life expectancy and a desire for improved quality of life, a rise in the frequency of surgical treatments for these women is anticipated. The aim is to compare complication, success, and satisfaction rates among elderly patients (aged >70 years) in comparison to younger women undergoing robotic sacrocolpopexy, thereby assessing the safety and efficacy of this surgery in this group of patients. METHOD: A prospective observational comparative study of 123 robotic sacrocolpopexies conducted between December 2016 and June 2022. Patients were stratified by age (cutoff point: 70 years). Baseline characteristics, type, and grade of prolapse, intra and postoperative data, complications, functional and anatomical outcomes, and satisfaction levels were collected. RESULTS: Among the 123 patients, 62.6% were under 70 years old, while 37.4% were 70 years or older, exhibiting similar baseline characteristics, prolapse grade, and type. The percentages of intraoperative (6.5%) and postoperative complications (4.4-9%) were comparable in both age groups. Furthermore, success and satisfaction rates exceeded 90%, with no significant differences between women under and over 70 years during a two-year follow-up. CONCLUSION: Robotic sacrocolpopexy is at least as effective and safe in women aged 70 years or older as in younger individuals, with no higher rates of intra and postoperative complications and similar rates of anatomical and subjective success.

Robot-assisted pudendal neurolysis in the treatment of pudendal nerve entrapment syndrome. / Neurólisis robótica del pudendo en el tratamiento del síndrome de atrapamiento del pudendo.

INTRODUCTION: Pudendal nerve entrapment syndrome (PNE) is characterised by the presence of neuropathic pain in the pudendal nerve (PN) territory, associated or not with urinary, defecatory and sexual disorders. Surgical PN decompression is an effective and safe alternative for cases when conservative treatment fails. The aim of this study is to describe the first robot-assisted pudendal neurolysis procedure performed in our country. MATERIAL AND METHODS: We describe step by step the technique of robot-assisted laparoscopic neurolysis of the left PN performed with intraoperative neurophysiological monitoring on a 60-year-old patient diagnosed with left PNE. RESULTS: The procedure was performed satisfactorily without complications. After 24h, the patient was discharged from the hospital. We observed a 50% reduction in pain measured using the visual analogue scale 2 weeks after the procedure, which remained after 10 weeks of the neurolysis. CONCLUSIONS: Robot-assisted neurolysis of the PN constitutes a feasible and safe approach, enabling better visualisation and accuracy in the dissection of the PN. Intraoperative neurophysiological monitoring is useful for locating the PN and for detecting intraoperative changes after the release of the nerve.

[Proceedings in the implantation of a laparoscopic radical prostatectomy program]. / Implantación de un programa de prostatectomia radical laparoscópica.

OBJECTIVE: To describe our proceedings in the implatation of our laparoscopic radical prostatectomy program (LRP). METHODS: Our working agenda and step-oriented implementation of our LRP program are shown. RESULTS: Four main steps were scheduled to acomplish this goal. These were: Preparatory phase, programed open conversion, development and analysis. Overlapping of each of these phase occured although their major content run on a time-basis. After basic skills acquisition and updating of our equipment we moved into the fixed-time open conversion we allowed us to progresively improve our performance without putting our patients into risks. Operative time of this phase exceeds that of our open cases in 63 minutes and no major complications took place. A rapid decrease in the operative time was noted after the first 15 cases (197' vs 264'). CONCLUSION: Implantation of a program of LRP can be done safely with a pre-planned program tailored to the needs and characteristics of each group and institution.

[Adequacy of urology departments in a health care model of hospitals network]. / Adecuación de Servicios de Urología en un Modelo Asistencial de Red de Hospitales.

UNLABELLED: The traditional health care model is currently facing new health requirements. The implementation of integrated urologic health systems can be one of the possible solutions to these needs. It is mandatory to explore a new health care model, which includes structural and organizational changes. The adequacy of the urology departments of IDCsalud-Madrid network hospitals, creating URORed, is a new system adaptable to constant changes, in order to offer professionalism and quality health care. OBJECTIVE: To describe the administrative/clinic management in the urology service of a health care model of Hospitals network (URORed at IDCsalud. Madrid), that has been included in a model of an Integrated network in a health care service. METHODS: In the period between November 2007 to October 2014, the urology departments of IDCsalud Madrid Group, have been included in a new organizational system, including 4 hospitals, currently with 27 urologists. Each center offers specific urologic services, sharing benefits and human resources. The same directive line leads all centers. RESULTS: The model offers an integrated and uniform urologic service to a specific population of 811.390 habitants (Population Census 2012), with capability to treat specific urologic diseases and to perform a correct clinical follow-up. CONCLUSIONS: Belonging to a health care model in network involves a change of attitude. It creates an organizational change, based on the processes and the results, which enables control of the management analytically, detecting the points that need to be optimized as well as those that are satisfactory. It implies developing a culture of learning and cooperation, so that the processes are fluent and have quality, to create clinical and technological projects in favor of new resource-generating research, based on the needs of the joint management of the hospitals network. The complexity of this model requires a work focused on the human resources, their concerns and their ability to coordinate actions to get results in terms of quality health care and professionalism.

[Renal transplantation and urinary infection. Review]. / Trasplante renal e infección urinaria. Revisión.

Urinary infection (UTI) is the most frequent infection after renal transplantation (RT). The literature shows and incidence between 10-98%. The risk of associated bacteraemia is close to 12%. Gram- bacteria are the most frequent causal agents (70%), although gram+, mainly enterococcus and staphylococcus, candida and some other exotic germs such as Corynebacterium are also potential etiological agents. Certain factors present in the receptor during pre-RT, RT itself and post-RT condition the development and evolution of UTIs. Clinical signs and symptoms are multiple ranging from asymptomatic bacteriuria to graft's abscess or septic shock. Incidence in females (54%) is higher than in males (29%). Immunosuppressive regimes based on Cyclosporin (35%) show lower incidence of UTI than those based in Azathioprine (50%). Antibiotic prophylaxis with Co-trimoxazol reduces incidence of UTIs at post-RT and delays the time of appearance of the first UTI episode.

[Testicular embryonal carcinoma with contralateral synchronous intratubular germ cell neoplasia: analysis of a case]. / Carcinoma embrionario testicular con neoplasia intratubular de células germinales sincrónica contralateral: análisis de un caso.

We report the case of a 20-year old male with a right testicular tumor. Bilateral orchidectomy was practised considering the synchronous clinical, ultrasonographical and histological (intraoperative biopsy) findings of the left testis. The definitive pathological report showed a right embryonal carcinoma with wide intratubular germ cell neoplasia (IGCN) of the contralateral testis. IGCN (formerly carcinoma in situ) is present in about 5% of cases in the contralateral gonad of those patients with a testicular neoplasm. More than 50% will develop cancer in that testis. Clinical and physical examination findings are usually unspecific. The diagnosis of IGCN is based on biopsy, although ultrasonography could give some data too, as some authors report. We analyze the therapy options for IGCN: (orchidectomy, chemotherapy, radiotherapy, or "wait and see"). In our case, the first one was made. Chemotherapy was used due to existence of retroperitoneal lymph node metastases, with an excellent follow-up afterwards.

Neurólisis robótica del pudendo en el tratamiento del síndrome de atrapamiento del pudendo / Robot-assisted pudendal neurolysis in the treatment of pudendal nerve entrapment síndrome

Introducción: El síndrome de atrapamiento del pudendo (SAP) se caracteriza por la presencia de dolor de características neuropáticas en el territorio del nervio pudendo (NP) asociado o no a alteraciones miccionales, defecatorias y sexuales. La descompresión quirúrgica del mismo constituye una alternativa eficaz y segura en los casos de fracaso de tratamiento conservador. El objetivo es describir el primer procedimiento de neurólisis robótica del pudendo realizada en nuestro país. Material y métodos: Se describe paso a paso la técnica de neurólisis laparoscópica asistida por robot del NP izquierdo realizada con monitorización neurofisiológica intraoperatoria en una paciente de 60 años de edad a quien se diagnosticó SAP izquierdo. Resultados: El procedimiento se realizó de forma satisfactoria sin complicaciones. Tras 24 h se procedió al alta hospitalaria. Se objetivó una reducción del dolor del 50% medida mediante Escala Visual Analógica a las 2 semanas del procedimiento, mantenida tras 10 semanas de la neurólisis. Conclusiones: La neurólisis robótica del NP constituye una vía de abordaje factible y segura, permitiendo una mejor visualización y precisión en la disección del NP. La monitorización neurofisiológica intraoperatoria es útil para la localización del NP y para la detección de cambios intraoperatorios tras la liberación del nervio

Introduction: Pudendal nerve entrapment syndrome (PNE) is characterised by the presence of neuropathic pain in the pudendal nerve (PN) territory, associated or not with urinary, defecatory and sexual disorders. Surgical PN decompression is an effective and safe alternative for cases when conservative treatment fails. The aim of this study is to describe the first robot-assisted pudendal neurolysis procedure performed in our country. Material and methods: We describe step by step the technique of robot-assisted laparoscopic neurolysis of the left PN performed with intraoperative neurophysiological monitoring on a 60-year-old patient diagnosed with left PNE. Results: The procedure was performed satisfactorily without complications. After 24h, the patient was discharged from the hospital. We observed a 50% reduction in pain measured using the visual analogue scale 2 weeks after the procedure, which remained after 10 weeks of the neurolysis. Conclusions: Robot-assisted neurolysis of the PN constitutes a feasible and safe approach, enabling better visualisation and accuracy in the dissection of the PN. Intraoperative neurophysiological monitoring is useful for locating the PN and for detecting intraoperative changes after the release of the nerve

Adecuación de Servicios de Urología en un Modelo Asistencial de Red de Hospitales / Adequacy of Urology Departments in a Health Care Model of Hospitals Network

El modelo sanitario tradicional se enfrenta actualmente a nuevas demandas de salud. La implantación de un sistema integrado de salud urológica puede ser una de las posibles soluciones a estas necesidades. Se requiere, por tanto, desarrollar e implementar un nuevo modelo asistencial, que incluya cambios a nivel estructural y organizativo. La adecuación de los Servicios de Urología de la Red hospitalaria idcsalud-Madrid, construyendo UroRed, constituye un nuevo sistema que se adapta a dichos cambios del entorno, para incrementar su profesionalidad y mejorar la calidad asistencial. Objectivos: Describir la gestión clínica de un Servicio de Urología corporativo (UroRed en idcsalud, Madrid) dentro de un modelo asistencial de Red de hospitales RISS (Red Integrada en Servicios de Salud). Métodos: En el período comprendido entre Noviembre de 2007 a Octubre de 2014, el Servicio de UROLOGIA del Grupo idcsalud Madrid, ha ido modelando un sistema organizativo constituido por 4 hospitales, con un equipo actual de 27 urólogos. Cada centro, ofrece y presta una determinada cartera de servicios especializados, compartiendo prestaciones y recursos humanos. Los diferentes equipos están gobernados por una misma línea de actuación. Resultados: El modelo ofrece una atención urológica integral y uniforme, dirigida a una población de 811.390 habitantes (Censo poblacional 2012), con capacidad concreta para la resolución de patologías específicas y continuidad clínica y asistencial. Conclusiones: Pertenecer a un modelo asistencial en red implica una modificación, un cambio de actitud. Conlleva un cambio organizacional basado en los procesos y los resultados que permitan controlar la gestión analíticamente, permitiendo detectar los puntos que requieren ser optimizados así como aquellos que resulten satisfactorios. Implica, por tanto, desarrollar una cultura de aprendizaje y cooperación para que los procesos sean fluidos y de calidad; crear proyectos clínicos y tecnológicos a favor de nuevas investigaciones generando recursos en base a las necesidades de la gestión conjunta del hospital. La complejidad de este modelo, requiere un trabajo centrado en las personas, sus inquietudes y su capacidad de coordinar acciones para obtener resultados en términos de calidad y profesionalidad asistencial

The traditional health care model is currently facing new health requirements. The implementation of integrated urologic health systems can be one of the possible solutions to these needs. It is mandatory to explore a new health care model, which includes structural and organizational changes. The adequacy of the urology departments of IDCsalud-Madrid network hospitals, creating URORed, is a new system adaptable to constant changes, in order to offer professionalism and quality health care. Objective: To describe the administrative/clinic management in the urology service of a health care model of Hospitals network (URORed at IDCsalud. Madrid), that has been included in a model of an Integrated network in a health care service. Methods: In the period between November 2007 to October 2014, the urology departments of IDCsalud Madrid Group, have been included in a new organizational system, including 4 hospitals, currently with 27 urologists. Each center offers specific urologic services, sharing benefits and human resources. The same directive line leads all centers. Results: The model offers an integrated and uniform urologic service to a specific population of 811.390 habitants (Population Census 2012), with capability to treat specific urologic diseases and to perform a correct clinical follow-up. Conclusions: Belonging to a health care model in network involves a change of attitude. It creates an organizational change, based on the processes and the results, which enables control of the management analytically, detecting the points that need to be optimized as well as those that are satisfactory. It implies developing a culture of learning and cooperation, so that the processes are fluent and have quality, to create clinical and technological projects in favor of new resource-generating research, based on the needs of the joint management of the hospitals network. The complexity of this model requires a work focused on the human resources, their concerns and their ability to coordinate actions to get results in terms of quality health care and professionalism

[Pyelocalicial diverticula]. / Divertículos pielocaliciales.

OBJECTIVE: To review the embryological and clinical aspects of the different types of pyelocaliceal diverticula, with special reference to the differential diagnosis and treatment. METHODS: Images of type I and II pyelocaliceal diverticula are shown. The conditions that cause difficulty in making the differential diagnosis are discussed. RESULTS: Urography continues to be the diagnostic method preferred and is sometimes aided by retrograde ureteropyelography. CONCLUSIONS: Pyelocaliceal diverticula are cystic eventrations of the upper urinary tract lying within the renal parenchyma that communicate through a narrow channel into the main collecting system. They occur in 0.2 to 0.5% of the population and are congenital in origin. Calyceal diverticula are frequently found incidentally on routine excretory urograms, but patients may complain of flank pain, hematuria or recurrent urinary infections. In the past, treatment required open renal surgery. Endourologic procedures are widely utilized today.

[Saint Liborius, patron of European urology. Iconography found in Croatia and Spain]. / San Liborio, patrón de la Urología Europea. La iconografía hallada en Croacia y España.

The discovery made by the group of Dr. Stella Fatovic-Ferencic in Varazdin (Croatia) of a painting of St. Liborius, patron saint invoked for calculi, and the painting of the Sevillian school (circa 1700) discovered by another group in Spain have led to the retrieval of part of the history of European Urology forgotten 250 years ago. Saint Liborius, bishop of Le Mans (France), died in 397, at the time the barbarian hordes were ravaging the Roman Empire, which had been divided into a Western and an Eastern Empire on the death of Theodosius I. Learning more about St. Liborius is of interest. Here is an example of the Graeco-Roman culture of antiguity that is passed on to the present time. The significance of both paintings and their differences are described. The article concludes that on the basis of his biography, St. Liborius should be considered the patron saint of Urology.

[Treatment of ureteral obstruction with auto-expandable metallic endoprosthesis]. / Tratamiento de la obstrucción ureteral mediante endoprótesis metálicas autoexpandibles.

OBJECTIVE: To evaluate the efficacy of Nitinol (Memotherm) self-expandible metal stents in the treatment of malignant and non-malignant ureteral obstruction in patients who are not eligible for surgery. METHODS: A total of 14 ureteral strictures (5 malignant, 9 non-malignant) in 13 patients were treated by the implantation of a Nitinol endoprosthesis. Eight were implanted by the antegrade and 6 by the retrograde route. A mean of 1.3 stents were implanted per patient. RESULTS: 85% of the stents were patent at a mean follow-up of 10.2 months (range 2-28). Four prostheses developed transient obstruction that was resolved by insertion of a double-J catheter for periods that ranged from 2 to 6 months. One stent required a permanent double-J catheter and another stent showed functional obstruction, although it was morphologically patent. CONCLUSION: The Nitinol self-expandible metal stent is effective in the treatment of malignant and non-malignant ureteral obstructions in patients who are not eligible for surgery due to the tumor stage or high surgical risk.

Implantación de un programa de prostatectomía radical laparoscópica / Proceedings in the implantation of a laparoscopic radical prostatectomy program

Objetivo: Exponer la implantación de nuestro programa de prostatectomía radical laparoscópica (PRL). Material y métodos: Se presenta la metodología y el plan de trabajo seguido en nuestro Centro. Resultados. La implantación del programa de PRL se hace en diferentes de fases coincidentes de manera parcial cronológicamente: fase de preparatoria, fase de reconversión programada, fase de desarrollo y fase de análisis. La primera es un periodo de aprendizaje de la técnica laparoscópica y de adquisición de equipamiento. La fase de reconversión realizada sobre nueve pacientes supone el comienzo de la técnica laparoscópica con una limitación en el tiempo para evitar alargamiento del tiempo quirúrgico y morbilidad. En nuestra experiencia, el incremento medio de tiempo quirúrgico ha sido de 63 minutos respecto a la prostatectomía radical abierta y no hemos tenido complicaciones mayores en este periodo. El tiempo quirúrgico medio disminuyó rápidamente tras los primeros 15 pacientes (197’ vs 264’). Conclusiones: La implantación de un programa de PRL es factible sin que conlleve riesgos añadidos a los pacientes haciéndolo mediante una planificación ordenada previamente que se debe ajustar a las particularidades de cada grupo e institución (AU)

Objective: To describe our proceedings in the implatation of our laparoscopic radical prostatectomy program (LRP). Methods: Our working agenda and step-oriented implementation of our LRP program are shown. Results: Four main steps were scheduled to acomplish this goal. These were: Preparatory phase, programed open conversion, development and analysis. Overlapping of each of these phase occured although their major content run on a time-basis. After basic skills acquisition and updating of our equipment we moved into the fixed-time open conversion we allowed us to progresively improve our performance without putting our patients into risks. Operative time of this phase exceeds that of our open cases in 63 minutes and no major complications took place. A rapid decrease in the operative time was noted after the first 15 cases (197’ vs 264’). Conclusion: Implantation of a program of LRP can be done safely with a pre-planned program tailored to the needs and characteristics of each group and institution (AU)

Carcinoma embrionario testicular con neoplasia intratubular de células germinales sincrónica contralateral: análisis de un caso / Embryonal carcinoma of the testis with synchronous contralateral intretubular germ cell neoplasia: a case report

Presentamos el caso de un varón de 20 años al que le fue detectado un tumor testicular derecho, siéndole practicada orquiectomía bilateral teniendo en cuenta los hallazgos sincrónicos clínicos, ecográficos e histológicos (en biopsia intraoperatoria) del testículo izquierdo, siendo el resultado definitivo anatomopatológico de carcinoma embrionario derecho con neoplasia intratubular de células germinales (NICG) difusa del teste contralateral. La NICG (anteriormente denominada carcinoma in situ), se presenta en un 5 por ciento de casos en la gónada contralateral de aquellos pacientes con un neoplasia testicular. Más del 50 por ciento desarrollarán cáncer en dicho teste. Las manifestaciones clínicas y los hallazgos de la exploración física suelen resultar inespecíficos. El diagnóstico de NICG se basa en la biopsia, aunque la ecografía pudiera asimismo proporcionar algunos datos, según refieren algunos autores. Analizamos las opciones de cara a la terapia de la NICG: (orquiectomía, quimioterapia, radioterapia, o actitud vigilante-expectante). En nuestro caso, fue la primera la que se llevó a cabo. Debido a existencia de metástasis linfáticas retroperitoneales fue aplicado asimismo tratamiento quimioterápico, con evolución posterior excelente (AU)

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