[Renal transplantation with living donors. A critical analysis of surgical procedures based on 40 years of experience]. / Transplante renal de donante vivo: un análisis crítico de estrategias quirúrgicas basado en 40 años de experiencia.

INTRODUCTION: Absolute priority in an LDKT programme are donnor safety and kidney optimal anatomical and functional preservation. Reduced donnor morbidities, both at short and long term, are important objectives. Excellent technical grafting is a must as are the strategies employed for facilitatig it. We revised the incidences of our whole LDKT programme (40 years 243 donors) to confirm if these exigences have been acomplished or a change to new surgical procedures is recommended. MATERIAL AND METHODS: Between 1968-2008 243 nephrectomies and grafting has been performed, a reduced number per year (A cadaver programme has been running simultaneously since 1964). For the nephrectomies a Turner-Warrick apprach was inititialy used and since 1973 a miniincisional, anterior, extraperitoneal approach of approximately 10 cm in length. The right kidney was removed in 75% of the cases and the right iliac area for the implant in 85% In adjacent opperating rooms, one team performs the nephrectomy while the other prepares and dissects free the grafting vessels. Most of the time the same senior surgeon performed both operatios: the nephrectomy and the implant. Peroperative and postoperative complications were evaluated by urologists and nephrologists in charge. RESULTS: No donors dead, organs lost or major complications in the donors have been documented. Minor complications such as intestinal paresia, wound infection, persistent incisional pain were common. Miniincisional abdominal approach reduced postoperative pain and hospital stay (4 days). At long term no incisional hernia or abdominal paresia have been documented. Simultaneous work reduces ischemia time (30-45 s warm: 30-45 min cold) and opperatig room occupation(patient preparation plus anesthesia plus operation) estimated in 90-120 min for the nephrectomy and 120-160 for the grafting. The responsibility of the senior surgeon in both procedures facilitates vessel selection for the grafting. CONCLUSIONS: No reasons have been found to reconvert our current nephrectomy procedure to laparoscopic or modify current surgical strategy. Superior safety of open surgery for donors and organs is confirmed. Pain and recovery time are reduced in laparoscopic surgery but not as much when compared with miniincisional approach. Open surgery permits optimal anatomical and functional organ extration facilitatig the quality of the implant. As numbers matter in laparoscopic surgery open nephrectomy is recommended for reduced LDKT programmes.

[The figure of the head of service (Chairman): what profile should have?]. / La figura del Jefe de Servicio: qué perfil debe de tener?

Great social-health care changes in the short term have been predicted that will seriously affect the departmental structure and care hierarchy of future hospital, universitary, public or private. The Spanish Association of Urology (AEU) wondered whether in these circumstances, in which the welfare and economic management of the hospital so-called "industrial" will dominate over other traditional aspects of the scientific hierarchy, social welfare and teaching of head Urology of service, will change his image, goals, functions, and ultimately its authority. Likewise which must be the attributes of this new generation of department heads. To this end the AEU call a roundtable requesting opinions and comments which are reflected in the enclosed text.

Polycystosis of the renal sinus or polycystic kidney disease Controversies, challenges and history of a shared discovery. / Poliquistosis del seno renal o hilioquistosis. Controversias, retos e historia de un descubrimiento compartido.

OBJECTIVE: To recall the history of the discovery of non-nephron cystic disease, detected simultaneously in 2 hospitals in Madrid, and the vicissitudes that the authors endured during the process of recognising this disease, while being ignored by the international scientific literature. MATERIAL AND METHOD: We analysed the authors' first publications and presentations, their correspondence relaying the difficulties in reporting the confusion with adult polycystic kidney disease (APKD) and the subsequent nosological identification of the process. We consulted with individuals who worked with the 2 authors to increase the accuracy and objectivity of the history report. RESULTS: We confirmed the authors' remarkable efforts in getting the process definitively recognised despite the notable difficulties. CONCLUSIONS: Rigorous clinical observation recognises processes ignored by the medical literature, and the correct application of the scientific method helps identify and reveal new nosological entities, confirming with this story's example that, in medicine, there are no exhausted issues.

Soluble guanylate cyclase beta1-subunit expression is increased in mononuclear cells from patients with erectile dysfunction.

The aim was to determine in circulating mononuclear cells from patients with erectile dysfunction (ED), the level of expression of endothelial nitric oxide synthase (eNOS), soluble guanylate cyclase (sGC) beta1-subunit and phosphodiesterase type-V (PDE-V). Peripheral mononuclear cells from nine patients with ED of vascular origin and nine patients with ED of neurological origin were obtained. Fourteen age-matched volunteers with normal erectile function were used as control. Reduction in eNOS protein was observed in the mononuclear cells from patients with ED of vascular origin but not in those from neurological origin. Although sGC beta1-subunit expression was increased in mononuclear cells from patients with ED, the sGC activity was reduced. However, only the patients with ED of vascular origin showed an increased expression of PDE-V. This work shows for the first time that, independently of the aetiology of ED, the expression of sGC beta1-subunit was increased in circulating mononuclear cells; however, the expression of both eNOS and PDE-V was only modified in the circulating mononuclear cells from patients with ED of vascular origin.

[Synchronous bilateral urothelial carcinoma of the upper urinary tract]. / Carcinoma urotelial ureteral bilateral sincrónico.

OBJECTIVE: Report a case of a synchronous bilateral urothelial carcinoma of the upper urinary tract without bladder affectation. METHODS: We describe the diagnosis and treatment of a case of a bilateral upper urothelial carcinoma. CONCLUSIONS: Synchronous bilateral urithelial carcinoma of the upper urinary tract without bladder affectation in an unusual occurance (1-5% of urothelial tumors) and radical surgery continues to be the treatment of choice, although it is possible to take a less aggressive approuch with selected groups of patient, in which we can achiese a survival rate similar to that which we obtain with radical surgery.

[Erectile dysfunction: the role of laboratory in the diagnostic and pronostic evaluation]. / Disfunción eréctil: papel del laboratorio en la evaluación diagnóstica y pronóstica.

OBJECTIVE: To review and to update the different laboratory tests recommended for etiologic diagnostic of erectile dysfunction and to evaluate the effect these tests could have on the pronostic and therapeutic strategy of this pathology. MATERIAL AND METHODS: We review the last articles related with etiopathogenics and pathophysiologics mechanisms of erectile dysfunction, including our studies on endothelial dysfunction and erectile dysfunction. RESULTS: The depth and extension of the laboratory protocol in erectile dysfunction is not necessaryly the same in all situations. The age, coincidence of comorbilities, set a different limit between patients demanding complementaries investigations that go beyond the basic request. CONCLUSIONS: The etiopathogenic laboratory work up in erectile dysfunction is currently changing incorporating news tests. The traditional search of commorbilities like diabetes, hepatic dysfunction, hypogonadism, hyperglucemia is getting broad with recents analitics evaluations related with potential markers of endothelial disease.

Urology at the European university: adaptations to the Bologna Plan. The model of the Autonomous University of Madrid.

The fundamental objective of the Convergence Plan of Bologna is to normalize, harmonize and standardize the teaching of medicine in European medical schools by implementing a similar curriculum. This objective assumes the presence of Urology as a university discipline in all European medical schools. At the same time, the teaching techniques and subject distributions have been modified, emphasizing practical teaching and active participation of the student in the acquisition of expertise and skills. This approach enhances the curricular presence of Urology and requires increased dedication from the teaching staff. These staff members, with limited face-to-face and classroom time, must inform and educate medical students on the broad healthcare commitment of urology as a surgical/medical specialty. The adaptation of the numerous European medical schools to the Bologna Plan raises a number of problems that can be easily overcome, as can be seen in the plan designed by the Faculty of Medicine at the Universidad Autonoma de Madrid.

What is a urodynamics study of upper urinary tract?

The urodynamic study of the upper urinary tract is a urologic procedure whose objective is to complement the information obtained by excretion urography in selected cases of documented or suspected upper tract obstruction. The procedure has several steps, all of which can be done by antegrade transcutaneous puncture of the kidney. The first and most important step consists of the simultaneous analysis of resting pelvic pressure, solute concentration in aspirated urine from the renal pelvis, and antegrade pyelogram. This set of data makes up the basic urodynamic evaluation and will be sufficient in many cases for diagnostic and prognostic purposes. However, in selected circumstances of equivocal dilatation or severe kidney atrophy, more complementary information can be gained using antegrade flow studies or temporary diversion by needle nephrostomy, respectively. These conclusions have been based on more than 300 urodynamic evaluations done by the author.

Percutaneous nephrolithotomy in transplanted kidney.

Renal transplant patients with urologic complications can be managed safely with percutaneous techniques. The development of renal calculi in transplanted kidneys is uncommon, but in these cases complications such as infection and urinary tract obstruction with impairment of graft function can occur. We report 2 cases managed successfully with percutaneous nephrolithotomy.

Management options for gynaecomastia and breast pain associated with nonsteroidal antiandrogen therapy : case report series.

OBJECTIVE: To present management options for gynaecomastia and mastodynia associated with nonsteroidal antiandrogen therapy, supported by relevant data and case studies. BACKGROUND: Gynaecomastia (male breast enlargement) and breast pain/ sensitivity (mastodynia or mastalgia) are pharmacologically expected adverse effects of nonsteroidal antiandrogen therapy for prostate cancer. They are caused by proliferation of glandular tissue in response to an increase in the ratio of estrogen to androgen. Gynaecomastia and mastodynia are benign conditions, and many patients choose to tolerate them as acceptable, usually mild or moderate, adverse effects of therapy. Recent data show that nonsteroidal antiandrogen monotherapy significantly reduces disease progression in localised and locally advanced prostate cancer, a finding that may result in wider and more long-term use of this treatment. Therefore, both clinicians and patients may benefit from increased awareness of the options available for the management of gynaecomastia and mastodynia. Management options, data and case studies: Management options for gynaecomastia and mastodynia are illustrated in a schematic flow diagram. Options identified are: (1) risk reduction using pretreatment breast irradiation; (2) stopping antiandrogen therapy; (3) acceptance of gynaecomastia and/or mastodynia in the context of the significant clinical benefit of antiandrogen treatment; (4) prompt treatment (liposuction/breast tissue excision, hormonal manipulation or pain control with irradiation or analgesics); and (5) later treatment (liposuction/breast tissue excision, hormonal manipulation or pain control with irradiation or analgesics). Where available, relevant data are discussed and the options are illustrated by case studies. CONCLUSIONS: The risk of developing gynaecomastia is lessened by prophylactic breast irradiation. Following the development of gynaecomastia, treatment options include readjustment of the estrogen-to-androgen ratio using antiestrogens, surgery in the form of liposuction or, for more advanced cases, breast tissue excision. Mastodynia may be controlled by post-treatment irradiation or analgesics.

[Aging and urology: is impotence the first symptom of aging?]. / Envejecimiento y urología: es la impotencia el primer síntoma de envejecimiento?

The clinical expression of ageing involves several organs with variable degrees of precociousness or intensity based on the apparatus or system. An early event in the ageing process may be the occurrence of asymptomatic, and difficult to recognise, periurethral hyperplastic nodules. On the contrary, such an obvious symptom and clinical entity as erectile dysfunction may become a highly relevant herald of ageing. And this will be more so if it appears in coincidence with widespread cardiovascular disease, specially if manifest through hypertension and ischaemic heart disease. The action of the urologist faced with a patient who asks for help for his erectile dysfunction cannot be limited to the evaluation of a simple organ disease.

[Urodynamic studies of the upper urinary tract. I. Introduction and diagnosis of the obstruction]. / L'exploration urodynamique du haut appareil urinaire. I. Introduction et diagnostic de l'obstruction.

Present experience precludes any assertion as to what a urodynamic exploration of the upper urinary tract exactly comprises, and what the fundamental indications are, despite the many attempts already made, which the author recalls. After establishing the conceptual difference between obstruction and stasis, the author goes on to analyze the existing methods for identifying the existence of an obstruction in cases of chronic dilatation. Noninvasive methods, intravenous urography, diuretic urography, conventional and diuretic renography and analysis of the parenchymal transit time, are all probably successful in establishing the existence of an obstruction in 85 per cent of cases of chronic dilatation of the upper urinary tract; but these methods cannot be used to quantify the obstruction, or even identify it in certain specific cases. In order to quantify the obstruction, recourse must be had to invasive methods, and more particularly, in view of the limitations of basal and diuretic pyelomanometry, to combined pressure/flow studies. The author analyzes the two possibilities open for the application of these procedures (constant flow perfusion, or perfusion with a constant pressure) together with their advantages and drawbacks.

[Urodynamic studies of the upper urinary tract. II. Pyelo-ureteral dilatation. Reversibility prediction test]. / L'exploration urodynamique du haut appareil urinaire. II. Dilatation pyélo-urétérale. Test de prédiction de la réversibilité.

For the correct performance of upper urinary tract repairs, it is essential to use methods which provide the necessary information concerning the potential reversability of the dilatation. This article analyzes the physiopathological foundations on which these methods must be based, and comments on the different procedures in common practice, such as the concept of radiological tonicity, peroperative histology, and preoperative draining. Special mention is made of anterograde urometry associated with simultaneous dynamic radiology, which provide precise information concerning the intraluminal pressure and the muscularization of the ureteral wall.

[Urodynamic exploration of the upper urinary tract. III. Recovery of obstructed kidney function]. / L'exploration urodynamique du haut appareil urinaire. III - Récupérabilité de la fonction du rein obstrué.

In cases of severe obstructive nephropathy, the quantification and potential reversability of a hydronephrotic atrophy is a fundamental factor in the choice between conservative and radical surgery. The information provided by non-invasive techniques, like excretory urography and the modern isotopic techniques, is limited by intercurrent phenomena, like infection and/or additional obstructive phenomena, which are frequent in patients presenting with hydronephrotic atrophy. It is therefore necessary, in such cases, to rely on direct procedures giving precise information concerning individual renal function, and, more particularly on percutaneous nephrostomy. The author's personal experience suggests that this procedure greatly improves the prognosis. But its results may be predictable in the light of a comparison of the analytical, manometric and radiological data provided by a transcutaneous punction of the kidney. In that event, it follows that the percutaneous nephrostomy is, of course, no longer indicated.

[Action of calcium antagonists on ureteral dynamics]. / Acción de los antagonistas del calcio sobre la dinámica ureteral.

We have investigated the action, in vivo, of a calcium antagonist on pyelouretheral dynamics. A surgical model consisting of a bilateral subcutaneous nephrostomy was used, which permits repeated studies in the same animal and simultaneous collection from both pyelouretheral tracts. Anterograde perfusion of a 1.5 ml/min flow gives rise to 7.6 +/- 2.3 contractions per minute of variable amplitude between 12.4 +/- 5.6 mm Hg. Verapamil, in intravenous 5-mg application, significantly reduces (P less than 0.05) the number of contractions per minute but does not mitigate or block the stimulus to a subsequent Norepinefrina injection. We conclude that Verapamil has a moderate but significant effect on pyelouretheral dynamics. We comment on the effect that this drug may have on the pyelouretheral tract when used for hemodynamic purposes and on its potential use in various urological affections.

[Prostatic benign hypertrophy: review of effectiveness, tolerance, and impact on quality of life of prolonged treatment with alfuzosin]. / Hipertrofia benigna de próstata: revisión de la eficacia, tolerancia e impacto en la calidad de vida del tratamiento prolongado con alfuzosina.

OBJECTIVES: To evaluate the effectiveness of Alfuzosin in terms of long term effect in BHP patients. To analyze the effectiveness according to the observer, the treatment compliance and the tolerance of alfuzosin, and specifically, cardiovascular and sexually adverse events. Also, to define the clinical profile of the BPH patients that spontaneously seek medical treatment in Spain. DESIGN OF THE STUDY: Observational, descriptive, multicentric and 6-month retrospective study. DATA SOURCES AND COLLECTION: From the patient reports of BPH patients treated with alfuzosin during more than 6 months, data gathered were, along with usually anamnesic data and physical exploration (age, symptoms, blood pressure, e.g.), those related to treatment response, effectiveness, compliance and tolerance of Alfuzosin in the first and second quarter. Data of the 1635 patients initially recruited were considered to define the clinical profile of this population. Effectiveness and tolerance analysis were undertaken with the 911 patients who followed the treatment during the 6-month study. RESULTS: After 6 months of treatment an improvement of the mean intensity of each of the urinary symptoms were statistically significant (p < 0.005). Also, the mean score of each of the analyzed variables and of the I-PSS global score were reduced significantly (p < 0.005). After 6 months of treatment the effectiveness evaluated by the observer was good or very good for the 88.5% of the patients. Treatment compliance was very good; from the 911 patients finishing the study, 96.4% continued with the initially prescribed treatment. Just 16 patients (3%) developed adverse events; measures undertaken were to modify the dosage or to interrupt the treatment (2 cases). The specific study of cardiovascular adverse events showed a mild reduction in the systolic (142 mmHg versus 137.86 mmHg) and diastolic blood pressure (83.53 mmHg) versus 80.72 mmHg), and the heart rate (76.80 l/m versus 76.04 l/m). The mean score of sexual life showed an improvement in all the items studied, although very slight. CONCLUSIONS: The usefulness, effectiveness and tolerance of a long term treatment with alfuzosin in HPB patients was confirmed. Alfuzosin is considered a first choice treatment in patients with the clinical profile described.

[Scrotal vasculitis simulating recurrent epididymitis]. / Vasculitis escrotal simulando epididimitis recidivante.

We present a case of scrotal vasculitis, of difficult diagnosis despite the patient's history, where it was necessary to resort to surgery in order to establish definitely its diagnostic differentiation with a specific epididymitis. Taking advantage of this uncommon form of presentation of scrotal vasculitis, in this case an evolved Schonlein-Henoch syndrome in a 35-year-old patient, we analyse the different forms of gonad, epididymis and scrotal affectation recognised in cases of vasculitis, with special reference to the forms of acute presentation, simulating testicle torsion.

[Testicular adrenal rests tumor: a difficult diagnosis]. / Tumor testicular de restos adrenales: un difícil diagnóstico.

This paper presents the case of a 19 year old patient with a well defined under palpation testicular tumor where surgical examination allowed a simple enucleation. Histological analysis during the operation reported it as a Leydig cells tumor but definitive analysis indicated tumor by adrenal residues. This histological argument illustrates the difficulty of making a differential diagnosis between both tumors, difficulty that goes beyond morphological and even clinical appreciation.

[Efficient, immediate or emergency ESWL: an attractive strategic alternative to be considered in the treatment of renal colic!]. / LEOC eficaz, inmediata o de urgencia: una atractiva alternativa estratégica a considerar en el tratamiento del cólico renal!

INTRODUCTION: Renal colic due to acute ureteral obstruction caused by lithiasic impact results in severe rise of intracavitary pressure. Traditional drug therapy (painkillers, anti-inflammatories, spasmolytics) is symptomatic and provisional, and pain can reappear when obstruction is maintained. A pathoetiological approach would be the ultimate therapy vs the symptomatic one. MATERIAL AND METHODS: From the beginning, the approach used at the Lithiasis-Lithotrity Unit at the FJD, once the ureteral stone is accurately identified during a renal colic, is that of immediate or emergency "in situ" SWEL together with the usual drug therapy. 15% of 2100 cases of ureteral lithiasis treated (1991-1999) were renal colic. RESULTS: Renal colic can be resolved in all cases (100%) even when fragmentation may be partial and/or require a second deferred SWEL on remnants of the first lithiasis. When obstruction has been resolved, pain does not reappear as it happens with the effects of analgesics. DISCUSSION: Placement of a ureteral catheter or nephrostomy for analgesia in order to perform deferred SWEL of the ureteral stone origin of the acute ureteral obstruction and the renal colic, do not improve SWEL results. There are physical reasons to support the practice of immediate or emergency "in situ" SWEL during a renal colic. Fragmentation of the obstructive stone together with the resulting ureteral oedema allow urine passage. Intracavitary pressure and pain disappear when the obstruction is withdrawn. CONCLUSIONS: Immediate, "in situ" or emergency SWEL in cases of obstructive ureteral stones during a renal colic, is an attractive strategic alternative for drug therapy that should be considered mainly in institutions with means to perform the procedure.

[Duloxetine and other tricyclic antidepressants: pharmacodynamic effects in the lower urinary tract]. / Duloxetina y otros antidepresivos tricíclicos: efectos farmacodinámicos en el tracto urinario inferior.

INTRODUCTION: During years the pharmacology of the lower urinary tract function has been presided by the protagonism of the autonomic nervous system and its components, sympathetic and parasympathetic. Recent investigations proved a greater complexity of micturional dynamics, attributing a more important role to the central nervous system (SNC), to the striated sphincter and to the afferent arc, offering a new opportunity to the Tricyclic Antidepressants (T.A.), reason for this general review. MATERIAL AND METHODS: Using as reference the work of the First Consultation on Incontinence (Montecarlo, 1999), the previous and later publications about T.A. have been reviewed, including experimental (isometric and "in vivo" studies) and clinical studies, investigating on pharmacological evidences, mechanism of action, tolerance and other effects of T.A. RESULTS: Only a reduced group of T.A. have been submitted to experimental evaluations and employed in clinical trials. The recent works on Duloxetine have waked up a special interest by their pharmacological potential. CONCLUSIONS: New knowledge on the peripheral and central control of the continence-miction dynamic offer new pathways for the treatment with T.A., whose effectiveness and tolerance are reviewed.