Deceased donor kidney procurement: Systematic review of the surgical technique.

INTRODUCTION: Kidney procurement procedure must be carried out following a standardized technique in order to optimize kidney grafts for their subsequent implantation. OBJECTIVES: Review of the available literature on kidney procurement procedure. MATERIAL AND METHODS: Narrative review of the available evidence on deceased donor kidney procurement technique after a search of relevant manuscripts indexed in PubMed, EMBASE and Scielo written in English and Spanish. RESULTS: Deceased donor kidney procurement can be divided into two groups, donation after brain death (DBD) and donation after circulatory death (DCD). Kidney procurement in DBD frequently includes other chest and/or abdominal organs, requiring multidisciplinary surgical coordination. During the harvesting procedure, the renal vascular pedicle must remain intact for subsequent implantation and reduced ischemia time. CONCLUSIONS: Adequate execution and perfect knowledge of the technique for surgical removal and anatomy reduces the rate of graft losses associated to inadequate harvesting techniques.

[Urinary calculi in myelomeningocele adults]. / Litiasis urinaria en adultos con mielomeningocele.

INTRODUCTION AND OBJECTIVES: The improvements in the management of newborns with myelomeningocele (MMC) have obtained a big increase in survival, allowing them to get longevity like never before, but data regarding urologic diseases during adult age are still missing. We herein evaluate the features of urinary lithiasis in adults born with MMC and the therapies used for its treatment. MATERIAL AND METHOD: We review 52 patients diagnosed at birth of MMC, between 18 and 40 years old, treated in our institution, with a mean follow-up of 6.7 years. RESULTS: 10 patients (19.2%) were diagnosed of urolithiasis. Three developed kidney calculi and one of them, with 7 more patients, developed bladder calculi (15.3%). The neurological level was < or = L2 in 3 cases, L2-S1 in 5, and > or = S1 in the other two. The type of neurogenic dysfunction of inferior urinary tract was multiple lesion of lower motor neurone in 6 cases, upper motor neurone in 1 case, multiple mixed lesion in 1 case and in case it was impossible to determine. Two patients had a bladder augmentation procedure and one of these with other 3 patients had a non-functional AMS-800 artificial urinary sphincter. Bladder stones were treated endoscopically in 14 procedures and by suprapubic cystolithotomy in 4 procedures, combined with removal of AMS-800 in 3 of them. One patient spontaneously passed a small stone. In one case, 2 ESWL and 2 percutaneous nephrolithotomies were needed. Three patients developed multiple recurrences during follow-up. CONCLUSIONS: Urinary lithiasis is common in adults with MMC. Some distinct features of these patients, together with their anatomical configuration and some therapies used in them, cause diagnostic, therapeutic and prophylaxis issues for the calculi they may develop.

[Primary seminal vesicle abscess: diagnosis and treatment by transrectal ultrasound]. / Absceso primario de vesicula seminal: diagnóstico y tratamiento mediante ecografía transrectal.

A 38 years old man with the only past medical history of bilateral orchiopexy 15 years ago is diagnosed of left primary seminal vesicle abscess. The patient is sent to our emergency service with an ultrasound finding of either dilated vas deferent or seminal vesicle abscess with hiperecogenic material inside it. The examination was performed after a 5 month history of purulent ejaculation. The diagnose of seminal vesicle abscess is confirmed by TRUS and, in the same procedure, drainage of the abscess was completed by needle-aspiration puncture. After this treatment the patient stay 12 hours at the observation room with intravenous antibiotics and is discharged home with oral antibiotics. We are interested in this case because of the low incidence of this pathology and the easy diagnosis and treatment by TRUS.

Hydrodynamic and biochemical effects of isolated hypothermic renal perfusion depending on the pump model and perfusion solution.

OBJECTIVES: To evaluate hydrodynamic, biochemical, and histological consequences of hypothermic isolated renal perfusion using a new computerized perfusion system. MATERIALS AND METHODS: The device that allowed us to obtain on renal hydrodynamics during perfusion included multiple parts. The organ was perfused at 4 degrees C with a constant flow either using a classic roller pump or a pump designed in our laboratory to employ vacuum or atmospheric pressure sequentially to achieve a truly pulsatile wave (vacuum-powered tubular pump). The study included 16 minipigs with Eurocollins or Belzer perfusion solutions sampled at predefined interval and histological studies of the organs performed. RESULTS: There was a significant difference in weight increase between the two types of pumps; those perfused with Eurocollins showed greater values than those with Belzer solution. Onset of nitric oxide (NO) in the perfusion solution increased inversely with the renal vascular resistance. The highest NO levels were observed with the Belzer solution and vacuum pump. CONCLUSIONS: Changes in renal hydrodynamics, as induced by perfusion wave form and solution type, may be recorded in real time using a computerized system. A vacuum pump with the Belzer solution achieved the best experimental results.

[Ureteral triplicity: trifid ureter with ipsilateral ureterocele and renal dysplasia in an adult with testicular seminoma]. / Triplicidad ureteral: uréter trífido con ureterocele ipsilateral y displasia renal en adulto con seminoma testicular.

Ureteral triplicity is a rare abnormality of which there are less than a hundred cases reported up to date. The possible absence of clinical signs can explain why this malformation passes unnoticed specially when there are blind branches and dysplastic renal segments. The paper presents the case of a 43 year-old male, attending the clinic on a testicle tumour consultation, in which in spite of the previously mentioned circumstances a preoperative diagnosis of trifid ureter with ipsilateral ureterocele and renal dysplasia was reached owing to the use of C.A.T.

[Management of pancreatic lesions in urologic surgery]. / Manejo de la lesión pancreática en cirugía urológica.

Surgical trauma of the pancreas cauda can occur when the renal hilum is dissected during left radical nephrectomy, mainly when normal anatomy is altered by the tumoral or inflammatory pathology. This lesion can be appreciated during the surgical procedure or else a pseudocyst or pancreatic fistula can become evident post-operatively. The urologist's knowledge of what the correct management both intra-operatively and postoperatively of this pathology should include will lessen the significant morbidity it implies. Presentation of a series of 6 patients presenting pancreatic trauma during left radical nephrectomy. Comments on the pathophysiology of this disorder, intra-operative management and post-operative treatment, specifically emphasizing the use of Total Parenteral Nutrition and Momatostatin IV.

[Genito-urinary tuberculosis in acquired immunodeficiency syndrome]. / Tuberculosis genitourinaria en el síndrome de immunodeficiencia adquirida.

Tuberculosis is being described as a highly associated entity with the acquired immunodeficiency syndrome (AIDS) in countries or geographical areas where this entity is endemic, even becoming its first clinical manifestation. Two cases of prostatic abscess are presented in patients with anti-HIV antibodies, who are parenteral drug users. In one of them, his genitourinary tuberculous infection was the first sign of AIDS. In the other, a previous association with tuberculous meningitis was found. The evolution and pathogenicity of tuberculous genitourinary in AIDS patients is discussed.

[Carcinoma of the penis: long-term follow-up]. / Carcinoma de pene: seguimiento a largo plazo.

Penis epidermoid carcinoma is responsible for about 1% of deaths by neoplastic diseases in developed countries. During a 5-10 years follow-up review, we found 14 patients, 9 of which started as localized stages in glans and/or prepuce. Lymph node affection was found in 9 cases, either at beginning of diagnosis or during follow-up. Lymphadenectomy, which demonstrated metastatic affection in 4 cases, was considered indicated in 6 patients. Two cases received inguinal chain radiotherapy and the remaining one underwent chemotherapy as first therapy. Percentage of actual survival rate, found after 5 years, among the 14 patients studied was 42.8% (6 cases), still unchanged after a 10-year follow-up. Five patients died due to their basic illness progression and 3 died of other tumour-unrelated processes. The paper analyzes the results obtained based on the literature reviewed, and discusses current therapy approaches for inguinal metastatic conditions.

[Variability of rectal examination of the prostate among various groups of observers]. / Variabilidad del tacto rectal de la próstata entre distintos groupos de observadores.

Rectal examination (RE) of the prostate gland is compulsory to rule out the presence of prostate cancer (PC). Empirically, it is defined as an examination burdened with a high degree of subjectivity and difficult to reproduce. The objective of this retrospective study is to evaluate RE concordance between different groups of researchers. In 133 patients referred to our Centre with suspected PC, RE was performed by three groups of experimented urologists (2 in-hospital and 1 out-hospital). Concordance between the different groups was evaluated using Kappa's index (K). Kappa's index between out- and in-hospital urologists was 70%, 71% and 78%. Concordance of RE findings between the different groups of urologists can be considered good, since no significant differences were found relative to ER positive predictive value.

[Morbidity of and tolerance to ultrasonography-guided transrectal biopsy of the prostate]. / Morbilidad y tolerancia de la biopsia transrectal ecodirigida de la próstata.

OBJECTIVE: The objective of the study is to evaluate the infectious complications of the ultrasound-guided prostate transrectal biopsy using two different antibiotic prophylactic regimes. Also, patient tolerance to ultrasound-guided transrectal biopsy is assessed. METHODS: Prospective study in 100 patients randomized to antibiotic prophylaxis with Pefloxacin (800 mg as single dose) versus Ciprofloxacin (250 mg/8 h/72 h). Tolerance data collection was done through completion of a questionnaire immediately after biopsy. RESULTS: Out of the 92 patients eligible for the study, 44 (48%) were assigned to Pefloxacin and 28 (52%) to Ciprofloxacin. In-house validation indicated both groups were matched. 90% patients showed good tolerance to the ultrasound technique and 81.5% patients to the transrectal biopsy. 31.5% patients presented no post-biopsy events; among the remaining only one patient (1%) required medical care and hospitalization. No patient had infectious complications. CONCLUSIONS: Prostate transrectal ultrasound and transrectal prostate biopsy was an approach well tolerated by most (81.5%) patients studied. Percentage of major complications was very small (1%), while post-biopsy events (haematuria, rectorrhage, etc) which do not require medical care should be considered not as complications but as effects intrinsic to the approach itself. Antibiotic prophylaxis whether with Pefloxacin or Ciprofloxacine was highly effective, although Pefloxacin is preferred due to its single dose administration and lower cost.

[Relationship between peripheral hypoechoic nodules of the prostatic gland and prostate cancer]. / Relación entre los nódulos hipoecoicos periféricos de la glándula prostática y el cáncer de próstata.

OBJECTIVE: The primary objective of the study was to evaluate the incidence of prostate cancer in the hypoechoic nodes located in the periphery of the prostate gland and its relationship with findings by digital rectal examination, and blood PSA and PSAD levels. MATERIAL AND METHODS: Retrospective study of 166 hypoechoic nodes detected and biopsed between January 1994 and August 1995, associating the pathoanatomical results with the findings from digital rectal examination, PSA and PSAD levels. Statistical analysis was done by estimation of confidence intervals for a 95% confidence level. RESULTS: Nodal cancer was present in 54.8% cases. The association of suspicious rectal examination increased the probability of cancer by 63% (IC95 = 51%-75%). The association of suspicious rectal examination and PSAD > 0.15 increases by 36.7% (IC95 = 11.7%-61.1%) the probability of having cancer versus a suspicious digital rectal examination alone. When no suspicious rectal examination was considered, the difference in the proportions observed for PSA > 10 versus PSA levels > 4 and < or = 10 ng/mL is 13.7% (IC95 = -2.1%-29.4%) and, for PSAD > 0.15 versus PSAD < or = 0.15 was 11.6% (IC96 = 3.8%-27.1%). CONCLUSIONS: Presence of a suspicious rectal examination and PSAD > 0.15 increased significantly the probability of prostate cancer being present in the hypoechoic node. When digital examination is not suspicious, neither the PSA or the PSAD levels influence significantly in the appearance of cancer.

[Conservative surgery in renal adenocarcinoma]. / Cirugía conservadora en el adenocarcinoma renal.

Conservative surgery in renal adenocarcinoma has originated a growing interest over the last few years for several reasons: 1. Refinement in renal imaging techniques. 2. Improvement in surgical techniques. 3. Greater number of tumours discovered incidentally usually at low stage, and 4. Good long-term results in patients treated this way. We conducted a retrospective analysis of 8 patients diagnosed with renal adenocarcinoma and treated with conservative surgery over a 5-year period, between January 85 and December 90. Complete tumour removal by enucleation was achieved in all patients, with low morbidity rates since only 1 patient had to be re-operated due to late haemorrhage. Since follow-up is short in most patients, no long-term results are provided. We conclude that enucleation is a simple technique which allows complete removal of small size renal adenocarcinoma with low morbidity and no mortality.

[Retroperitoneal laparoscopic nephrectomy: a case report]. / Nefrectomía laparoscópica por vía retroperitoneal: caso report.

Presentation of the first exclusively retroperitoneal laparoscopic nephrectomy performed on a female patient diagnosed with chronic pyelonephritis in the right kidney who referred frequent discomfort in the ipsilateral lumbar fossa as well as sporadic urinary infections. The entire procedure was performed without entering the peritoneal cavity, creating a space in the retroperitoneum, using for that hydrostatic dilation following Gaur's recommendations and introducing in that space a total of 4 trocars. Surgery lasted 3 hours an 35 minutes, with a post-operative stay of 3 days; the anaesthetics used after surgery was minimum and patient's return to her usual daily activities was almost immediate after discharge. Considering our group's previous experience in laparoscopic nephrectomies, both in humans (another 3 cases) and experimental surgery (18 pigs), we believe retroperitoneal approach is a huge step ahead in urological laparoscopic surgery, since this is the typical approach in our specialty and allows a closer contact with the condition being treated. On the other hand, the combined retro- and transperitoneal accesses will involve-are already involving-a greater variety of laparoscopic techniques in urology.

[Ultrasonographic and pathologic differences between non-palpable prostate cancer (T1c) and palpable lesions detected with rectal examination]. / Diferencias ecográficas y patológicasógicas entre los cánceres de próstata no palpables (T1c) y los palpables al tacto rectal.

OBJECTIVE: To determine whether non-palpable cancers (T1c) have different ultrasound and pathological features from other palpable cancers of the prostate gland. MATERIAL AND METHOD: PSA levels, ultrasound features and Gleason score in 178 patients diagnosed with prostate cancer between 1994-1995 were compared. Correlation of pathological findings in surgical sections from 47 patients undergoing radical prostatectomy. RESULTS: 22% tumours were non-palpable. No difference was observed between both age groups (p = 0.5) and PSA levels (p = 0.09). Differences were noted in favour of palpable cancer in PSAD (p = 0.01), incidence of ultrasound nodes (p < 0.001), capsule changes (p < 0.001), seminal vesicles (p < 0.001), Gleason score (p = 0.006) and bone scan (p < 0.05). Two (14%) patients with non-palpable cancer showed no tumour in the prostatectomy section. Apart from these 2 patients, no differences were found between both groups in terms of Gleason score (p = 0.3), local stage (p = 0.7) and node involvement (p = 0.4) in patients undergoing radical prostatectomy. CONCLUSIONS: 86% patients with non-palpable prostate cancer has clinically significant tumours and showed no differences from the rest of tumours undergoing radical prostatectomy.

[Yield of transrectal ultrasonography in the diagnosis of prostatic cancer in symptomatic patients with normal rectal digital test]. / Rendimiento de la ecografía transrectal en el diagnóstico del cáncer de próstata en los pacientes sintomáticos con tacto rectal normal.

The purpose of this retrospective study is to evaluate the incidence of prostate cancer in symptomatic patients with non-suspect rectal examination and its correlation to PSA, PSAD levels and ultrasound findings. A total of 235 patients with non-suspect rectal examination underwent transrectal ultrasound and echo-guided prostate biopsy to assess an echographic node, PSA > 10 ng/mL and/or PSAD > 0.15 Incidence of prostate cancer was 16% and no correlation was seen to either PSA (95CI = 5%, 14.9%) or the existence of ecographic nodes (95CI = 5.2%, 22.2%), mainly in the subgroup of patients with PSA > 10 ng/mL and no identifiable echographic node (95CI = 5.5%, 29.5%). A PSA > 10 ng/mL or identifiable echographic nodes in symptomatic patients with non-suspect rectal examination did not involve a risk factor for prostate cancer, however a PSAD > 0.15 within the group with PSA > 10 ng/mL with no echographic nodes did involve a risk factor.

[Effectiveness of transrectal ultrasonography in local staging of prostatic cancer]. / Eficacia de la ecografía transrectal en el estadiaje local del cáncer de próstata.

OBJECT: To evaluate the value of rectal examination, transrectal ultrasound and their association in patients with prostate cancer undergoing radical prostatectomy. MATERIAL AND METHODS: Retrospective study on 56 patients who underwent radical prostatectomy between 1995-1995, mean age 63.2 +/- 10 years, to compare local clinical staging of extracapsular dissemination and seminal vesicle invasion performed by rectal examination and transrectal ultrasound with pathological findings in the prostatectomy specimens. The sensitivity, specificity, VPP, VPN, accuracy and percentage of under- and over-staged patients were assessed. RESULTS: Prevalence of locally advanced disease was 48%. Sensitivity to detect extracapsular dissemination was significantly higher with ultrasound (38%) than rectal examination (6%). Association of both techniques increased the sensitivity (50%) though not significantly; sensitivity to detect vesicle invasion was very low (14%). Accuracy of ultrasound to establish an overall definition of the local stage was 66%, but 59% patients with locally advanced disease were understaged and only 10% patients with localized disease were overstaged. CONCLUSIONS: Transrectal ultrasound showed low sensitivity to define the locally advanced disease mainly at the seminal vesicle level, with acceptable specificity. Overall evaluation of findings with RE and TRU increase discreetly the efficacy of prostate capsule staging.

[Usefulness of free PSA/total PSA ratio in the diagnosis of prostatic cancer in symptomatic patients with PSA levels ranging from 2.5 to 20 ng/ml]. / Utilidad del cociente PSA libre/PSA total en el diagnóstico del cáncer de próstata en pacientes sintomáticos con niveles de PSA entre 2,5 y 20 ng/ml.

OBJECTIVE: To evaluate the value of free PSA/total PSA ratio (fPSA/tPSA) to boost total PSA (tPSA) specificity in the diagnosis of prostate cancer in a series of symptomatic patients. MATERIAL AND METHOD: Prospective study on 334 patients presenting symptoms compatible with PBH and tPSA (ProStatus, Wallace Oy, Turku, Finland) between 2.5 and 20 ng/ml, and mean age 67.2 +/- 7 (49-87). Patients were divided into 3 groups: Group I (normal DRE and tPSA between 2.5 and 10 ng/ml)--189 patients. Group II (normal DRE and tPSA between 10 and 20 ng/ml)--78 patients. Group III (suspicion DRE and sPSA between 2.5 and 20 ng/ml)--67 patients. For each group, the sensitivity, specificity and ROC curves were calculated for several cut-off values of the lPSA/tPSA ratio. RESULTS: Group I--Prostate cancer was diagnosed in 11% (20/189) patients. Significant differences were found only in the lPSA/tPSA ratio (p = 0.01). Using 27% as the cut-off value, cancer would have been diagnosed in 95% (19 of 20) patients, decreasing the total number of negative biopsies by 21% (39 of 189). Group II--Prostate cancer was diagnosed in 19% (15/78) patients. The only significant differences found were in prostate volume (p = 0.02). Using 30% as the cut-off value, 93% (14 of 15) patients with cancer would have been diagnosed, decreasing the total number of biopsies by 6.5% (5 of 78) and the number of negative biopsies by 8% (5 of 63). Group III--Prostate cancer was detected in 72% (48/67) patients. Significant differences were found in lPSA/tPSA ratio (p = 0.003), prostate volume (p = 0.02) and presence of ultrasound nodes (p = 0.004). Using 25% as the cut-off value, 96% (46 of 48) of patients with cancer would have been diagnosed, decreasing the total number of biopsies by 13% (9 of 67) and the number of negative biopsies by 47% (9 of 19). CONCLUSIONS: We advise use of lPSA/tPSA ratio only in patients with normal DRE and tPSA between 2.5 and 10 ng/ml. Biopsing patients with lPSA percent equal to or lower than 27% would have prevented 23% of negative biopsies while still maintaining a diagnostic sensitivity of 95%.

[Renal abscess in patients diagnosed with AIDS and disseminated tuberculosis]. / Abscesos renales en pacientes diagnosticados de SIDA con tuberculosis diseminada.

Presentation of two cases of renal abscess formation in patients with stage IV C-1 AIDS and active associated tuberculosis. The microorganism isolated in the first case was S. aureus. Culture of the second cases was artefacted since antibiotic administration had already been started. Also, both patients showed abdominal abscesses, at spleen and liver level in the first case, and prostatic level in the second case, both compatible with Mycobacterium tuberculosis dissemination. Both cases showed a lethal evolution. The role played by the immunodeficiency as a precipitating agent in the extrapulmonary tuberculosis and in the formation of renal abscesses is analyzed.