[Relationship between a benign fibroepithelial polyp and a pelvic nephroblastoma: report of a case]. / Relación entre un pólipo fibroepitelial benigno y un nefroblastoma piélico: a propósito de un caso.

The purpose of this paper is to report one case of left pyelic Wilms' tumour in a 17-year old male patient. Pre-operative diagnosis was complicated by a background of prior surgery on the same kidney due to a benign fibroepithelial polyp. The possible concomitences are analyzed while the relevance of an extensive pathoanatomical study to avoid possible diagnostic errors is emphasized.

[Is it possible to do without bone gammagraphy in the staging of prostatic cancer?]. / Es posible prescindir de la gammagrafía ósea en el estadiaje del cáncer de próstata?

Since the discovery of the prostate specific antigen, and its use as tumoral marker, not only this has been shown to have a significant application for the diagnosis and evaluation of prostate cancer management, but also to be an eventual help to predict occurrence of bone metastasis. A retrospective study was conducted in 50 patient with prostate cancer, with mean age of 74 years (range 56-90), where PSA levels were analyzed and then correlated with the results obtained with bone scintigraphy. Our work results were that, given a 40% prevalence of the metastatic disease, no patient had PSA values under 10 ng/ml and, at the same time, bone dissemination, i.e., a 100% negative predictive value. Thus, we can state that in our group, we could have given a PSA cut-off value over 10 ng/ml to perform bone scintigraphy, without making any staging mistake.

[Analysis of the reliability of ultrasonic estimates of the posturination+ residue]. / Análisis de la fiabilidad de la estimacion ecográfica del residuo postmiccional.

OBJECTIVES: The most precise procedure for the measurement of residual urine volume is bladder catheterization; nevertheless, it takes real associated morbidity. Our objective is to define the accuracy of bladder ultrasonography when residual volume estimation is performed. METHODS: Thirty patients were studied. Ultrasound estimation of residual volume was undertaken with Simpson's method V = (pi/6) x L x T x AP. Obtained values were contrasted with the post-catheterization registered ones. RESULTS: The mean ultrasound estimated residual urine volume was 82.1 ml., versus 156.5 after catheterization. The mean difference was 74.4 ml. (significant, p < 0.001). Correlation coefficient was 0.93. Regression equation was calculated, a well as the corrected formula that, according to the outputs of our study, offers greater reliability in the estimate of the aforementioned volume. Ultrasound sensitivity when proper estimation of volumes equal or greater to 100 cc. is carried out was only 47%, opposite to the elevated specificity (100%) for this purpose. CONCLUSIONS: Transabdominal ultrasound underestimates, to a large extent, the values of residual urine volume. We consider that ultrasound estimation of residual volume constitutes an alternative to be kept in mind; nevertheless, the formula to calculate this volume through bladder diameters introduces an important error and so, it should be corrected.

[Limitations of ultrasonography in the clinical course monitoring of bladder tumors]. / Limitaciones de la ecografía en el control evolutivo de los tumores vesicales.

Ultrasonography is a fairly innocuous test in the follow-up of bladder tumours. Its results, however, can not be superposed to those of cystoscopy. This study aims to identify the risk factors for failure of transabdominal ultrasonography in the FU of bladder tumors. The influence of the primary tumour, sex and age of patients on the ability of ultrasonography to detect relapses was analyzed. Chi square and Student's t tests were used to associate the characteristics of primary tumours and patients to the results of ultrasonography. Student's t test was used to estimate the effect of diagnostic oversight in terms of annual recurrence rate and progression. The characteristics of primary tumours where relapse was detected or overlooked had no influence on the results of ultrasound follow-up as neither did age and sex. No differences were detected in recurrence rate of patients with anticipated (0.57) or overlooked (0.58) tumours. Although differences in progression rates (4.76% and 9% for overlooked and identified tumours, respectively) were substantial, they did not reach statistical significance. There are no features in the original tumour or the patient to anticipate the failure of ultrasound monitoring. Multiple and/or small relapses are overlooked more frequently that single and/or large ones, and tumours located in lateral walls, base and dome may be unnoticed. In spite of oversights, alternate ultrasound/cystoscopic monitoring does not compromise the outcome of the disease.

[Complete urethral duplication in a girl]. / Duplicación uretral completa en una niña.

Urethral duplication is a very rare malformation which occurs almost exclusively in males. Associated genital and urinary malformations are frequent, and the approach in symptomatic cases in surgical management. This paper presents one case of a full double urethra in a 9-year old girl with repeat urinary infections and incontinence. The accessory urethra was surgically removed using perianal and abdominal access. Evolution has been favourable with disappearance of symptomatology.

[Reliability of routine cytological diagnosis in bladder cancer]. / Fiabilidad del diagnóstico citológico de rutina en el cáncer vesical.

OBJECTIVES: To establish the reliability of three cystopathologists for cytological diagnosis of primary bladder tumors. METHODS: Pre-operative voided urine specimens of 71 patients with bladder cancer and 55 healthy controls were retrospectively and blindly reviewed by 3 independent cytologists, and their results--positive for bladder cancer, negative or inconclusive--were compared with each other. The estimation of the interobserver agreement was calculated using the weighted kappa-coefficient (k). A multivariative analysis was carried out to identify the factors associated with the disagreement among the three observers. The sensitivity and specificity for each of the participants were calculated in order to clearly identify the origin of the disagreement, in terms of the performance of the diagnostic test in the hands of each observer. A comparison of the overall diagnostic performance was made by plotting sensitivity versus 1-specificity. RESULTS: The weighted k coefficient among observers was 0.46. The multivariative analysis did not identify any variable that could have caused such disagreement. Large differences in sensitivity and specificity were detected between observer number 1 (sens., 0.90, spec., 0.45) and observers number 2 (sens., 0.67, spec., 0.72) and number 3 (sens., 0.71, spec., 0.80), but the overall diagnostic performance (sensitivity vs 1-specificity) was superimposable in the three cases (p = ns). CONCLUSIONS: Simple, reproducible and agreed-on diagnostic criteria should be established to yield reliable results in a group of cytologists. The consideration of individual diagnostic performances can give a false idea of homogeneity between observers. In this field, concordance analysis makes quality control reliable and should be a routine procedure of any pathology department.

[Changes in prostatic histological composition in subjects with prostatitis]. / Modificaciones de la composición histológica prostática en los sujetos con prostatismo.

OBJECTIVES: To explore the links between the histological composition of the prostate and the symptoms related to the clinical BPH. MATERIAL & METHODS: The prostates of 34 patients with symptoms of BPH and 17 asymptomatic patients were biopsied. Using light microscopy, the ratio of stromal to glandular surfaces was calculated. The main dimensions of 5 epithelial cells randomly selected, were examined under electron microscopy in each case. The number and length of microvilli, and the number of secretory granules were determined. The results of symptomatic and asymptomatic subjects were compared by means of Student's t and Mann-Whitney's U tests. RESULTS: The mean ratio of stromal and glandular surfaces came to 4:1 and 6.5:1 in the symptomatic and asymptomatic patients, respectively. The difference was not statistically significant (p = 0.18). Although the average cellular surface of the symptomatic patients was inferior to that of the asymptomatic subjects (74 and 88 mu2. respectively), the differences did not reach statistical significance (p = 0.14). Similarly, the mean nuclear surface of the symptomatic and asymptomatic patients (19.5 and 20.8 mu2, respectively) did not differ (p = 0.48). No differences were detected in the number of secretory granules and microvilli, nor in the length of the microvilli. CONCLUSIONS: The occurrence of symptoms related to the clinical BPH is not due to differences in the composition of the prostate. No clear links seem to exist between the structural changes in the epithelial cells and the development of symptoms. Considering the proportions of epithelium and stroma, therapy focused in the prostatic stroma should yield the best results.

[Results of a screening program for prostatic cancer]. / Resultado de un programa de screening para el cáncer de próstata.

OBJECTIVE: To set up the epidemiology of prostate cancer in the geographical area of Getafe, Madrid (Spain) and to detect curable prostate cancer. The results of screening 2.576 men are reported. PATIENTS & METHODS: Patients underwent digital rectal examination (DRE) and PSA determination. Patients with suspicious DRE or PSA greater than 4 ng/ml were further evaluated with transrectal ultrasonography (TRUS) and biopsy. The diagnostic performances of the tests or combinations of tests were determined. RESULTS: Mean age was 59.9 years (median 58 years). Ninety-four patients (3.6 per cent) had abnormal DRE while PSA was higher than 4 ng/ml in 169 patients (6.5% of the total). 6.8 biopsies were needed to prove one cancer. The higher sensitivity corresponded to the PSA (93%). The test of greatest specificity was the rectal examination (97%). Positive predictive value raised to 78.9% when both DRE and PSA were abnormal. Advanced tumor stages were more common (39.4%) than in previous experiences. CONCLUSIONS: PSA should be the first diagnostic test when screening for prostate cancer. Neither the DRE nor the TRUS have any place in patients with PSA below 4 ng/ml. In summary we can't encourage screening programs for prostate cancer so far.

[Results of transrectal echography in the study of female urinary stress incontinence]. / Resultados de la ecografía transrectal en el estudio de la incontinencia urinaria de esfuerzo femenina.

The development of echographic transducers allows now to study Female Urinary Exertional Incontinence (FUEI) using different approaches (vaginal, perineal and transrectal). A total of 122 transrectal echographies were performed. Based on the clinical symptoms: 14 patients are continent, 15 report micturition urgency, 11 micturition urgency plus FUEI, and 82 FUEI. All parameters Xrest, Yrest, AUVPrest, Xexertion, Yexertion, AUVPexertion, X', Y', AUVP' were measured. Three groups were defined: Group I, normal ultrasound diagnosis; Group II, vesical neck hypermobility; Group III, FUEI using Kolmogorov-Smirnov's test, the data fits a standard distribution curve and the results were analyzed through a variance analysis and Newman-Keul's test. During Valsalva's manoeuvre, patients with FUEI show greater caudal mobility of the vesical neck which becomes more significant as the degree of FUEI increases. Dorsal mobility is also greater in patients with FUEI although this parameter is of no use to quantify the degree of FUEI. Posterior urethro-vesical angle variability only discriminates patients with no FUEI from those with a higher degree of FUEI.

[Role of PSA velocity in the detection of prostate cancer. A study of 986 males]. / Papel de la velocidad del PSA en la detección del cáncer de próstata. Un estudio con 986 varones.

OBJECTIVE: To analyze the role of PSA velocity (PSAV) in the detection of prostate cancer (Pca) when compared to other valid alternatives. PATIENTS AND METHODS: From a Pca screening program, 986 men were evaluated in two visits (601 of them agreed for a third visit). Serum PSA was performed in every visit (PSA1, PSA2 and PSA3). All Pca diagnosed after PSA1 were excluded. Criteria for biopsy (PSA2 and PSA3) were PSA > 4 ng/ml, or PSAV > 0.7 ng/ml/year. Diagnostic performance of PSAV was compared with other options (PSA alone, DRE, and PSA density -PSAD-). RESULTS: Median age was 57 years. Median interval between visits were 679 days and 852.5 days respectively. During PSA2, 122 biopsies were indicated (91 performed). After PSA3, 78 were indicated and 24 done. This great proportion of not biopsied men was due to refusal. Seven Pca were detected during PSA2, and 5 during PSA3. Sensitivity of PSAV (two draws) was 0.86, specificity 0.95, missed 1 cancer of 7 and needed 7.5 biopsies per cancer. When three PSA samples available, PSAV missed 2 cancers of 5, and 2.7 biopsies per cancer needed. PSA alone detected 86% of the cancers, multiplying by 2 the number of biopsies needed. Not DRE, nor PSAD improved the diagnostic performance of PSAV when combined with this parameter. CONCLUSIONS: Diagnostic performance of PSAV was found to be unacceptable in our hands. The need for a third biopsy in these studies make them difficult to reproduce. Validation of PSAV is a difficult task to achieve, we think its role remains questioned.

[Obstructive nature of the "double-J" ureteral catheter in idiopathic retroperitoneal fibrosis]. / El carácter obstructivo del catéter ureteral en "doble-J" en la fibrosis retroperitoneal idiopática.

INTRODUCTION AND OBJECTIVES: "Double-J" ureteral stents are commonly used for ureteral diversion, Obstruction of these devices is rare in the absence of certain circumstances. The objective of this article is to discuss the origin of stent obstruction in the Idiopathic Retroperitoneal Fibrosis (IRF) context, and to suggest the most suitable type of urinary diversion. METHODS AND RESULTS: We presented three cases of extrinsic ureteral compression due to IRF who were inserted soft polyurethance "double-J" stents (Urosoft, Angiomed brand), 7 Fr. with multiple side holes. These stents finally turned out as obstructive ones, and needed to be changed for other types of diversion. CONCLUSIONS: Steroid treatment constitutes the first option for these patients, but if ureteral obstruction occurs, diversion should be carried out. We prefer internal ureteral diversion with spiral-reinforced ureteral stents, being also valid options percutaneous nephrostomy or external ureteral stents made of a more rigid type of polyurethane, according to the case. When a soft polyurethane stent is used in a patient with FRI, we should perform a very strict follow-up with appropriate image studies, since the possibility of being not effective always exists.

[Antimicrobial prophylaxis in urology]. / Profilaxis antimicrobiana en urología.

UNLABELLED: Antimicrobial prophylaxis in surgery has proven to be effective in controlled randomized trials. Usage in Urology is known at least since the '30s although its effectiveness has only become known since 1979. METHODS: Review of literature related to surgical antibiotic prophylaxis, more specifically urological surgery, basically from 1991 to 1995, but without overlooking those papers that have become classics due to their impact. RESULTS AND CONCLUSIONS: Efficacy of antimicrobial prophylaxis in urological surgery is nowadays beyond all doubt. Usage is indicated in the presence of sterile urine and dosage must be short, in single dosis in the immediate pre-operative or within 24 hours after the procedure. However, there is a number of issues that deserve to be treated in more detail for better understanding. Those are the establishment of adequate prophylactic regimes in renal transplantation and the use of antimicrobials based on their pharmacokinetic characteristics to optimize the prophylactic purpose.

[Alternatives to the cystoscopic control of bladder neoplasms]. / Alternativas al control cistoscópico de los tumores vesicales.

OBJECTIVE: Cystoscopy is the most sensitive technique for the detection of bladder tumor recurrence, but is the least accepted by the patient. In our Service, 25% of cystoscopies are poorly tolerated. Our experience with alternatives to cystoscopy is described. METHODS: Using cystoscopy as the gold standard, we analyzed the diagnostic yield of cytology, vesicorenal US and the combination of vesicorenal US and cytology. The techniques were compared for sensitivity vs 1-specificity. RESULTS: The sensitivity of the alternative techniques was limited. At best it was 0.81 when US and cytology were used in combination. The specificity was low and the incidence of false negatives was 7.3%. Similarly, the diagnostic yield was better when US and cytology were used in combination (sensitivity vs 1-specificity = 0.77). CONCLUSIONS: No technique, alone or in combination, can replace cystoscopy. However, alternate use of combined US and cytology with cystoscopy is efficient in the follow-up of bladder tumors and can reduce the number of cystoscopies. The delay in the diagnosis of recurrence probably has not negative negative influence on the history of the disease.

[Analysis of prognostic factors in superficial bladder tumors]. / Análisis de los factores pronósticos en los tumores vesicales superficiales.

OBJECTIVE: When the traditional prognostic factors (tumor grade, stage, size, number and cytological findings) are used as guidelines for intravesical therapy of superficial bladder tumors and the reported results are compared, it is not uncommon to find unexplainable differences. This study was conducted to determine the prognostic factors for tumor recurrence and progression before instituting any type of adjuvant therapy for superficial bladder tumors. METHODS: 81 consecutive patients with primary superficial bladder cancer (stage Ta-T1, grade 1-3) were entered into a surveillance protocol and controlled for a mean period of 14 months (range 3-44). Patient individual features (sex and age) and tumor characteristics (grade, stage, size, number, cytological findings) were analyzed to determine the risk of tumor recurrence and/or progression. RESULTS: Logistic regression analysis identified age as the only independent prognostic factor for recurrence, which was 6.37 fold (2-42) more frequent for subjects aged 65 years or older. Given the low progression rate (3 cases; 4.8%), a formal risk analysis could not be performed. CONCLUSION: The factors used to predict recurrence (tumor grade, stage, size, number and cytological findings) were not found to be independent in the present series. Certain predictors of tumor aggressiveness-such as age-, which could modify tumor biology, were found to predispose to tumor recurrence.

[Basic ideas on the diagnosis and treatment of burns of the male genitalia]. / Nociones básicas sobre diagnóstico y tratamiento de las quemaduras en los genitales masculinos.

OBJECTIVES: The main characteristics of burn injuries of the male genitalia and the basic principles of treatment are described. METHODS/RESULTS: Of 77 patients in the Burns Unit of this hospital, 7 (9%) had lesions to the external genitalia. Four of these patients had superficial dermal (grade IIA), 2 had deep dermal (grade IIB) and one had total dermal or subdermal burn injuries (grade III-IV) to the genitalia. The superficial lesions were treated medically and deep burns required surgery. RESULTS: At one-year follow-up, no functional sequelae were observed except in the patient with total dermal burn injuries, who developed right testicular atrophy and azoospermia, but preserved erection and ejaculation. CONCLUSIONS: Burn injuries to the external genitalia are uncommon. These lesions do not often require surgical treatment, and usually heal spontaneously. Despite their dramatic appearance, cure with no cosmetic or functional sequelae is often the rule.

[Does some relation exist in the size and histological composition of the prostate?]. / Existe alguna relación entre el tamaño y la composición histológica de la próstata?

OBJECTIVE: To determine if the histological composition of the prostate-the proportion of glands and stroma-depends on its size. METHODS: Prostate volume was determined by abdominal US; transurethral biopsy of the prostate was performed in 22 patients (mean age 64.8 years) with BPH or bladder tumor. Morphometric analysis of a fragment of the prostate was performed using light and electron microscopy. The stroma-epithelial ratio (SER) and the density of prostatic vascularization (DPV), and the nuclear and cellular areas of 5 epithelial cells in each case, were determined. The ratio of the sum of granular to cellular areas (secreto-cellular ratio), and the nuclear-cytoplasmic ratio (NCR) were determined. The pearson coefficient and linear regression equation that best correlated the prostate volume and the rest of the variables. RESULTS: The mean SER was 4:1 and the DPV was 15.18 vessels/mm2. The cellular and nuclear areas were 79.6 and 21.2 mu2, respectively. The secreto-cellular ratio was 0.083 and the NCR was 0.28. The prostate volume showed no mathematical relationship with SER (r = 0.016, p = 0.9) or DPV (r = 0.026, p = 0.9). Only a random association between the US prostate volume and the cellular and nuclear areas, and the secreto-cellular and NCR could be observed. CONCLUSION: The histological composition of the prostate cannot be determined by the US prostate volume.

[Predictive factors on postoperative quality of life in transurethral resection of prostatic adenoma]. / Factores anticipadores de la calidad de vida postoperatoria en la resección transuretral del adenoma de próstata.

OBJECTIVE: To identify the traits of patients undergoing transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) that best predict the outcome of the procedure; i.e., quality of life (QOL) changes. METHODS: The prostatic symptoms and the pre- and postoperative QOL of 151 patients submitted to TURP for BPH were evaluated by the IPSS AUA-7 questionnaire. The available preoperative variables (age, symptoms, US prostate size and DRE findings) were correlated with the QOL changes. Thereafter, the relationship between the available postoperative variables and the QOL changes were analyzed. RESULTS: Of the available preoperative variables, symptoms and prostate size were the only factors that significantly influenced the variability of the QOL changes. Multivariate analysis permitted anticipating only 14% of that variability (r2 = 0.14). Analysis of all of the available post-TURP variables showed postoperative symptoms to be the only variable with a statistically significant relationship with the QOL changes. This model provides an explanation for the 60% interindividual variability of the QOL changes (r2 = 0.77, r2 = 0.603; p < 0.001). CONCLUSIONS: We found no mathematical relationship between the preoperative factors and the QOL changes. These changes depended largely upon the postoperative symptoms. The remaining parameters analyzed in this study--including the weight of resected prostatic tissue--showed a weak influence, which suggests that the prostates react differently to TURP.

[Abscessed primary retroperitoneal leiomyoma]. / Leiomioma retroperitoneal primario abscesificado.

OBJECTIVE: To describe a case of primary retroperitoneal leiomyoma presenting as pelvic abscess. METHODS/RESULTS: A patient who had consulted for fever and hypogastric and perineal pain is described. The diagnostic imaging techniques disclosed a heterogeneous pelvic mass compatible with an abscess, which was drained. After the purulent material had been drained, the mass was removed surgically. The pathological analysis of the surgical specimen disclosed a retroperitoneal leiomyoma. CONCLUSION: An abscessed primary retroperitoneal leiomyoma is a very uncommon tumor.

[Unusual cause of acute penile deformity: thrombosis of the superficial dorsal vein of the penis]. / Una causa inusual de deformidad peneana aguda: la trombosis de la vena dorsal superficial del pene.

OBJECTIVES: To analyze a case of acute shortening and dorsal bending of the penis arising from a thrombosed superficial vein of the penis. METHODS: Patient history, physical examination and duplex US findings are detailed. RESULTS: With a duplex US scan showing no venous flow in the dorsal vein proximal to the root of the penis and after penile fracture, paraphimosis and the presence of foreign bodies had been discarded, the diagnosis was easily made and the lesion completely healed in two weeks. CONCLUSIONS: In evaluating penile deformities, thrombosis of the superficial dorsal vein of the penis must be considered.