[Radical laparoscopic nephroureterectomy]. / Nefrectomía radical laparoscópica.

As with the increasingly common presence of laparoscopic surgery in renal adenocarcinoma, the same situation is also occurring with radical management of tumours of the upper urothelium. In this type of clinical condition, it is important to emphasize the different ways to mobilise the distal ureter (with transuretral resection or unroofing, pure laparoscopy, or open), and to take into account that this tumour has the highest risk of implantation at the ports of entry. Here, we conduct a literature review and up-date of the different approaches to the distal urethra.

[Laparoscopic adrenalectomy]. / Adrenalectomía laparoscópica.

Laparoscopic extirpation of the suprarenal gland is considered the 'gold standard' of surgery for benign conditions, but its indication in suprarenal cancer is still controversial. In this article, we review the pros and cons of the laparoscopic approach in the different disorders that affect the adrenal gland, pheochromocytoma, cancer, partial and bilateral adrenalectomy, etc.

[Laparoscopic ureterolithotomy of an iliac ureteral stone forgotten for more than eight years]. / Ureterolitotomia laparoscópica de un cálculo de uréter iliaco olvidado durante más de ocho años.

INTRODUCTION: Laparoscopic ureterolithotomy recently rises as a new option in the treatment of ureteral calculi, particularly those of the greatest size, hardness or impactation. We describe such an indication to resolve a case of forgotten for more than eight years and severely obstructive ureteral stone. PATIENT AND METHOD: A 64 years-old male received extracorporeal shock wave lithotripsy for a right distal ureteral stone and, simultaneously, a left impacted iliac ureteral calculi was discovered, at the confluence of an incomplete duplication of the ureter, for which treatment was recommended, but deferred by the patient. Eight years after, the same stone caused a massive dilatation with poor function of the upper pole moiety and slightly preserved function of the lower pole moiety of the left kidney. Two intents of retrograde ureteroscopy failed because of impossibility to reach the stone. Transperitoneal laparoscopic ureterolithotomy was performed in lateral decubitus position, with double J in place and three 10 mm ports. After identification of the dilated ureter, an V-shape ureterothomy was made and the stone mobilized and extracted. The ureter was stented and the ureterothomy closed with intracorporeal suture. The patient had a postoperative stage of four days and a mild functional recovery. DISCUSSION: If the usual treatment options (extracorporeal lithotripsy and ureteroscopy with intracorporeal lithotripsy) failed, then laparoscopic ureterolithotomy is less invasive than open ureterolithotomy. However, the indications of laparoscopic ureterolithotomy are restricted because substantial laparoscopic experience is needed to cope with possible technical difficulties.

[Ancient urology in Galicia (Spain)]. / Urología antigua en Galicia.

INTRODUCTION: Although Urology is a recent branch of medical science and practice, it is not a contradiction to talk about ancient Urology, as a reflection on the ways of getting sick and treating genitourinary diseases in past times, sufferings that are recognized if compared to the present-day ones. This paper takes into account the social view of the history of medicine and tries to reject either the intention to create a mythic past for urology or to underestimate the ancient practices because of irrational or not scientific. MATERIAL Y METHOD: Review based on primary and secondary sources, with reference to the medicine and surgery of the urinary tract and genitalia in Galicia (Spain) and the Iberian peninsula, from the ancient and medieval periods, to the appearance of modern, anatomo-clinic medicine in the XVIIIth century. RESULTS: Because of the pilgrimage through the Way of Saint James to Santiago de Compostela, many centers of great importance for the attention of sick people rose up in Galicia, like the Monastery of Saint Martin Pinario and the Hospital of the Catholic Kings, where traditional European standars of patient care and use of medicinal plants were followed in. Ancient medicine and surgery of the urinary tract and genitalia had in Galicia, characters of great interest, such as doctor Romano, instructor of Galician practitioners in catheterisation and urethral dilatation, and important thinkers such as the physician- philosopher Francisco Sanchez and the erudite monks Sarmiento and Feijoo, whom, without being doctors, may be considered as pioneers of modern evidenced-based medicine. COMMENTS: The importance that the Galician hospitals had in past times and the works of several characters related to Galician country, had a distinguished place in the ancient history of the medicine and surgery of the urinary tract and genitalia.

[Valdivia supine position as the best option for percutaneous surgery of renal calculi in morbidly obese patients]. / La posición supina de Valdivia como mejor opción para la cirugía percutánea de los cálculos renales en el paciente con obesidad mórbida.

INTRODUCTION: Treatment of the morbidly obese patient with symptomatic renal calculi is an interesting urological challenge. Extracorporeal shock wave lithotripsy is frequently not possible for several reasons, and many urological centers match these patients as one of the residual indications for open surgery of kidney lithiasis. MATERIAL AND METHOD: Two patients with body mass index more than 50 k/m2 and symptomatic kidney stones were treated with percutaneous nephrolithotomy in the supine position described by Valdivia (slightly lateralized supine decubitus). Standard instrumentation for percutaneous surgery and the semi-rigid ureteroscopy were used, through an Amplatz sheath proximally transfixed with a polypropylene stitch, so to avoid its lost under the fatty skin. Both patients were rendered stone-free without significant morbidity. DISCUSSION: The advantages of Valdivia position in those patients are clear, both for the commodity of the surgical team, -because time may be spared and help needed to mobilized the patient is less-, as well as for what concerns to the anesthesia, because cardio-respiratory restrictions created by a general anesthesia in prone are greater and more severe in the obese patient. This position seems to be more suitable than other ones recommended for percutaneous nephrolithotomy in the obese patients, such as prone decubitus on a surgical saddle, or lateral decubitus position, that may compromise the radiological control of the operation.

[Doctor Manuel Cobas Núñez (1885-1956), pioneer of urology and uroradiology in Galicia]. / El Doctor Manuel Cobas Núñez (1885-1956), pionero de la urología y de la uro-radiología en Galicia.

INTRODUCTION: The development of urologic radiology with intracavitary and intravenous contrast agents played an essential role in the rise of Urology as a surgical speciality, in agreement with other circumstances that made it both possible (the invention of endoscopic instruments and laboratory technics to study the urine and the kidney function, advances in anaesthesia, asepsis, control of hemorrhage and infection), and necessary (because of social request for these specialised medical services). MATERIAL AND METHOD: Study of the life and work of Manuel Cobas Núñez (1885-1956), whose surgical practice and publications pioneered the modern Urology and Uroradiology in Galicia (Spain). RESULT: After being trained in Necker Hospital (Paris) and Instituto Rubio (Madrid), Cobas was one of the first to practice urology in Galicia, with a high interest in surgical diseases of the upper urinary tract. His knowledge of renoureteral surgery was outstanding for the time. In august 1931 he published "Pielografia ascendente y pielografia descendente", one of the first and best documented books on upper urinary tract examination using retrograde and intravenous pyelography, written only months after marketing of the first intravenous contrasts agents. COMMENT: Working in private practice, out of the academic fields, Cobas was a protagonists of the beginning of Galician modern urology. His publications and book on pyelography show that he was one of the first experts in renal surgery and must be also recognized as a pioneer of uroradiology in Galicia and Spain.

[Bullet injury of the bladder. In the novel "La Regenta" by Leopoldo Alas "Clarín"]. / Una herida de bala vesical. En la novela "La Regenta" de Leopoldo Alas "Clarín".

Some great literature works show medical pictures of high historical value. In "La Regenta", by Leopoldo Alas Clarín (1852-1901), considered the best XIX-century Spanish novel and one of the most important of the whole Spanish literature, there is a faithful account of a bullet wound of the bladder: the possibility of making the diagnosis, the complications and inevitable poor prognosis are depicted, since in the story the wound is followed by peritonitis and death of the wounded character, with the attending doctors rejecting a transfer to the hospital or a surgical intervention. This episode reminds us of an important chapter in the History of Surgery and Urology: the diagnosis of trauma wounds of the urinary tract, based over a long time on the data provided by urethral catheterisation; and the treatment of penetrating abdominal wounds in general, a matter of discussion between partisans and detractors of surgical exploration, that had a high mortality until well into the XX-century, when modern means of vital support, anaesthesia and antiseptics were on hand.

[Hydrocele and cholesterol granuloma of the tunica vaginalis simulating a tumor in echography]. / Hidrocele y granuloma por colesterol de la túnica vaginal simulando un tumor en la ecografía.

OBJECTIVE: A case of cholesterol granuloma of tunica vaginalis, with an equivocal ultrasound image but typical histopathological picture, is described. PATIENT AND METHOD: A 33-year-old man complained of a painless scrotal mass of 17 years duration. The mass was 10 cm in diameter, could not be transilluminated and appeared as paratesticular and solid on ultrasound, suggesting a tumor. At operation an old hydrocele with cholesterol crystals and cholesterol granuloma of tunica vaginalis was found. A partial resection of tunica vaginalis was performed, sparing the testis. COMMENT: Cholesterol granuloma is a rare inflammatory reaction of tunica vaginalis, that may simulate an intrascrotal tumor on physical examination, on ultrasound and at operation.

[Oxidized cellulose (Surgicel) mimics an abscess after laparoscopic partial nephrectomy]. / Celulosa oxidada (Surgicel) simulando un absceso después de nefrectomía parcial laparoscópica.

INTRODUCTION: Oxidized cellulose gauze (Surgicel) left into the surgical bed can mimic a gas-forming abscess in the close postoperative image studies, because of air trapped within the interstices of the gauze, before that being degraded. PATIENT AND METHOD: In the early postoperative CT scan of a laparoscopic partial nephrectomy due to renal cell carcinoma, two small collections of gas were found, at the sites where Surgicel was placed. Being aware of the surgical details, they were not confused with an abscess. COMMENT: Small collections of gas into a Surgicel gauze may be detected until more than a month after surgery, imitating a bacterial abscess, but the clinical context, operative reports and a good communication between the surgeon and the radiologist should avoid this mistake.

[Unilateral renal cystic disease]. / Enfermedad quística renal unilateral localizada.

Unilateral and localized cystic disease of the kidney, is characterized by the substitution of either all or a portion of one of the kidneys, by no encapsulated, multiple simple cysts. We present a case--to our knowledge the first in the Spanish bibliography-, of this rare benign condition that needs to be recognized to be differentiated from more transcendent ones. Contrary to autosomal dominant polycystic kidney disease, it is unilateral, it is not familiar, and it is neither progressive nor associated with renal insufficiency or with cysts in other abdominal organs. Lack of encapsulation allows, in general, to distinguish it from multilocular cystic nephroma and cystic renal carcinoma.

[Bacteremia caused by Clostridium perfringens as a complication of ureterosigmoidostomy]. / Bacteriemia por clostridium perfringens como complicación de una ureterosigmoidostomía.

A 63 year old male underwent cystectomy and ureterosigmoidostomy after diffuse carcinoma "in situ" of the bladder was discovered, and thereafter, various episodes of pyelonephritis and metabolic imbalance, in one of them, a left pneumo-ureter and a positive blood culture for Clostridium Perfringens and enterococci was detected. Empiric therapy with Aztreonam was started, and changed after to high-dose intravenous amoxicillin. Two months later the ureterosigmoidostomy was converted to an ileal conduit. The patient has remained asymptomatic on subsequent controls.

[Diffuse xanthogranulomatous pyelonephritis with a renocolic fistula neglected for more than two years]. / Pielonefritis xantogranulomatosa difusa con fistula renocólica inadvertida durante más de dos años.

INTRODUCTION: Although reno-colic fistula is a well-known complication of the diffuse form of xanthogranulomatous pyelonephritis, the features of the case here presented are unusual because of the paucity of symptoms and long lasting evolution of the disease before it was diagnosed. CLINICAL CASE: A 75 year-old woman was seen at the emergency room complaining of fever and malaise. Physical and laboratory examination showed anemia and a left abdominal mass, and on X-ray and abdominal CT, a gross stone and huge left renal and extrarenal xanthogranulomatous pyelonephritis with renocolic fistula were disclosed. A review of her clinical record showed an X-ray performed two years before by the attending family clinician, with identical gross calculi and gas into the kidney. Nephrectomy, caudal pancreatectomy and partial colectomy were accomplished with good results. COMMENT: This case of poor-symptomatic xanthogranulomatous pyelonephritis that destroyed the kidney and induced a renocolic fistula, is unusual because it was neglected for more than two years due to unawareness of the clinical and radiological picture.

[Laparoscopic pyelolithotomy in a pelvic kidney]. / Pielolitotomía laparoscópica en riñón pelviano.

INTRODUCTION: Pelvic renal ectopia bearing stones is a particularly rare case of complex calculi. Several percutaneous and laparoscopic procedures had been proposed in the last years to treat this challenge problem in a minimally invasive way. CLINICAL CASE: We describe the procedure of laparoscopic pyelolithotomy under general anesthesia, using three port sites, in a male patient with symptomatic stones in a left pelvic kidney with normal function. Two stones were successfully removed, with the help of flexible nephroscopy through a port, and the pyelotomy was closed with intracorporeal suture. COMMENT: Laparoscopic pyelolithotomy of a pelvic kidney is a minimally invasive technique that is not difficult to perform, making laparotomy unnecessary. Laparoscopic technique must be take into account when dealing with the infrequent complex stone patient candidate to an open stone surgery. A review of the Spanish bibliography shows this to be the second reported case of pelvic kidney calculi treated by laparoscopic pyelolithotomy.

[Late pancreatic metastasis from renal carcinoma]. / Metástasis pancreática tardía por carcinoma renal.

The appearance of solitary late metastases of renal cell carcinoma has seldom been documented. A male patient, who 5 years ago underwent left radical nefrectomy for renal cell carcinoma, presented with a solitary pancreatic metastasis (an uncommon site of metastasis for renal cell carcinoma), which was successfully treated with partial pancreatectomy. The diagnostic, treatment and prognostic implications of solitary late metastases are discussed.

[Encrusted alkaline cystitis and malacoplakia]. / Cistitis alcalina incrustante y malacoplaquia.

Urinary infection due to urea splitting bacteria leads to a rise in urinary pH, favouring the precipitation of calcium salts and struvita crystals. If deposited on the surface of a bladder with chronic inflammation or some other previous lesion, may produce an alkaline encrusted cystitis, now a rare condition. In the case here presented, occurred in a 69-year-old male. Corynebacterium urealyticum grown in the urine, and some foci of malakoplakia were found in the area of encrustation endoscopically excised. This case seems to be the third example of alkaline encrusted cystitis associated with malakoplakia reported in the bibliography. These two conditions share similar clinical signs and may probably have a common aetiopathogenesis.

[Diffuse involvement and rapid progression of high-grade transitional carcinoma in a kidney transplant recipient]. / Afectación difusa y progresión rápida de un carcinoma transicional de alto grado en un paciente trasplantado renal.

In renal transplant patients, an increased risk of cancer has been seen, higher than in the general population, and the more frequent genitourinary neoplasms are the kidney and bladder ones. Moreover, in those patients the pattern of tumor growth is very rapid, with early tendency to local and systemic dissemination. The case here presented, a patient with kidney transplant 3 years before, with high grade, superficial transitional cell carcinoma involving the whole bladder, the pelvis and the ureter of the right native kidney, shown this fast progression. Four months after radical cystectomy plus bilateral nephroureterectomy, the disease progressed to intraperitoneal and hepatic metastases.