[Experimental laparoscopic renal autograft as learning laparoscopic model]. / Autotrasplante renal laparoscópico experimental como modelo de aprendizaje de técnica laparoscópica.

INTRODUCTION: Laparoscopic surgery requires a long training period of time in which the complexity of the training is increased. GOALS: The technique presented in this paper has been developed in order to find an experimental model that allows us to improve the learning of the vascular suture. Our main goal was to evaluate this technique as an experimental model for the vacular anastomosis, not to obtain a functional autotransplant. In this regard, here we summarize our experience during the first two cases performed. MATERIAL AND METHODS: Laparoscopic renal autotransplant was perfomed in female lab pigs weighing 15-20 kg. International Experimental Animal Care rules were accomplished. RESULTS: After sacrifizing the animals, only one case of vascular thrombosis was observed. The other cases showed normal arterial and venous flow. CONCLUSIONS: Experimental Renal Laparoscopic autotransplant constitutes a good surgical model. We are trying to implement the technique in the clinics in the next future.

[Laparoscopic urinary diversions]. / Derivaciones urinarias laparoscópicas.

INTRODUCTION: The treatment of the invasive bladder cancer and the recurrent T1G3 is clearly established in radical cystectomy and pelvic linphadenectomy. One of the fields where the laparoscopic approach implies more doubts is the treatment of bladder cancer, because it requires experience enough in pelvic laparoscopic surgery and the urinary diversion implies great technical difficulties to the laparoscopic approach. OBJECTIVES: The main goal of this article is to report our results with the urinary diversion after laparoscopic radical cystectomy where the ureteral anastomosis has been performed by a laparoscopic approach. METHODS: From January 2005 to December 2007 we have performed 67 laparoscopic radical cistectomies. We conducted 28 laparoscopic urinary diversions with our technique: 7 neobladder with an average age of 54, 85 years and 21 ileal conduit with an average age of 69, 15 years. RESULTS: The averagesurgical time for enterocistoplasty with laparoscopic urethral and ureteral anastomosis is of 5 hours and 30 minutes. For the cutaneous ureteroileostomy with laparoscopic ureteral anastomosis the average surgical time has been of 4 hours and 30 minutes. We have had 1 case of urinary leakage in the laparoscopic neobladder and 3 cases in the laparoscopic ileal conduit (14%). We have not intestinal dehiscence nor ileal-ureteric stenosis. The average hospital stay for laparoscopic neobladder is for the 85% of cases of 13.6 days, and of 11.8 days for the 77.7% of ileal ureteric laparoscopies. DISCUSSION: The laparoscopic radical cystectomy is still a procedure reserved for groups with great experience in laparoscopic surgery. Nowadays, the most accepted procedure by most groups includes perform the cystectomy by a laparoscopic approach and the urinary diversion by an open approach. There is no evidence of the advantages of laparoscopic urinary diversion. It is necessary to perform comparative studies to clearly define the role of laparoscopic surgery in the urinary diversion.

[Laparoscopic nephron sparing surgery. Initial experience]. / Cirugía renal laparoscópica conservadora de parénquima. Experiencia inicial.

We present our initial experience in laparoscopic nephron sparing surgery. It's a technically advanced procedure requiring considerable minimally invasive expertise. This technique is particularly attractive compared to an open conventional procedure with its larger incision and associated morbidity.

[Open and laparoscopic adrenalectomy. 10 years review]. / Suprarrenalectomía abierta y laparoscópica. Revisión de 10 años.

We present a 10 years open adrenalectomy review in our Service and the beginning of laparoscopic adrenalectomy in the last year as a part of the retroperitoneal laparoscopic program at the Hospital Universitario La Paz . The first laparoscopic adrenalectomy was done after 21 retroperitoneal laparoscopic surgeries. Our initial experience has been so good that we have reduced the contraindications for this technique and we have increased the number of laparoscopic surgery cases.

[Development of a laparoscopic radical prostatectomy program in an university center]. / Implantación de un programa de prostatectomía radical laparoscópica.

The aim of this article is to report our experience in setting up a laparoscopic radical prostatectomy programme. We believe that knowledge of the difficulties we faced at the start will be useful for those who wish to implement a programme like ours. We hope that by explaining the steps we took as well as our conclusions and recommendations this difficult task can be made easier.

[Retroperitoneal laparoscopic surgery; initial experience in the Hospital La Paz]. / Cirugía retroperitoneal laparoscópica; experiencia de los 6 primeros meses del Hospital La Paz.

We present the initial results of retroperitoneal laparoscopic surgery in the Hospital Universitario La Paz from July 2004 to December 2004. The program started after 2 years of pelvic laparoscopy surgery practice. The initial experience has been so good that we have reduced the contraindications for this technique and we have increased the number of laparoscopic surgery cases.

[Experimental laparoscopic renal autograft]. / Autotransplante renal laparoscópico experimental.

Laparoscopic surgery requires a long training period of time in which the complexity of the training is increased. The technique presented in this paper has been developed in order to find an experimental model that allows us to improve the learning of the vascular suture. Our main goal was to evaluate this technique as an experimental model for the vascular anastomosis, not to obtain a functional autotransplant. In this regard, here we summarize our experience during the first two cases performed.

[Laparoscopic adrenalectomy. Five-year experience]. / Suprarrenalectomía laparoscópica. Experiencia de 5 años.

OBJECTIVE: Adrenal conditions requiring surgery are uncommon and are usually seen in several surgical departments. Our experience in laparoscopic management of adrenal pathology after almost five years of use of laparoscopy for retroperitoneal conditions at our center is reported. MATERIALS AND METHODS: A total of 37 laparoscopic adrenalectomies were performed over 53 months for benign and malignant conditions. The transperitoneal approach was used in most cases (97%) because of the greater surgeon experience with this route. Pregnancy and suspected periadrenal infiltration were considered as absolute contraindications. RESULTS: Mean operating time was 90 minutes, mean intraoperative bleeding 80 ml, and mean hospital stay was 2 days. The main complication was one death. A malignancy was found in 4 patients (10%), while all other patients (90%) had a benign condition, including 8 pheochromocytomas. CONCLUSIONS: Laparoscopy is considered to be the gold standard for benign adrenal conditions. When the malignant mass is a single metastasis from a primary tumor, the laparoscopic approach appears to be reliable. When the malignant lesion is a primary adrenal tumor, laparoscopic management is more controversial, although the results reported by experienced surgeons in their series appear to be adequate.

[Laparoscopic nephron-sparing surgery. 5 years' experience]. / Cirugía conservadora de parénquima renal laparoscópica. Cinco años de experiencia.

INTRODUCTION: Laparoscopic nephron-sparing surgery is among the most complex urological procedures currently performed. Open surgery continues to be the gold standard of care, but the laparoscopic approach is gaining ground slowly but surely. Our 5 years' experience is reported. MATERIALS AND METHODS: From September 2004 to March 2009, 38 laparoscopic nephron-sparing procedures were performed at our hospital. A transperitoneal laparoscopic approach was used in all cases, with en bloc clamping of renal hilum in most patients. RESULTS: Mean operating time was 141 min, mean intraoperative bleeding 130 mL, mean warm ischemia time 24 min, and mean hospital stay 3.3 days. Bleeding was the most common complication (requiring transfusion in 13.5% of patients). Positive surgical margins were found in 5.4% of patients. CONCLUSIONS: Adequate selection of the patient (tumor size, location) and the procedure to be used, surgeon experience, and surgical skills are essential for achieving good oncological results and for minimizing the complications of this demanding procedure.

A review of penile cancer.

UNLABELLED: Cancer of the penis is a rare tumour in Europe and mainly affects the elderly patient population. The aim of this paper was to analyse and study the characteristics of this tumour, in our patient population. MATERIALS AND METHODS: A retrospective study was conducted on penile tumours diagnosed and treated in the Urology Department of the Hospital Universitario La Paz, Madrid, in the last ten years. RESULTS: A total of 34 patients were diagnosed and treated. The mean age at presentation was 71.27 years. The mean time between symptoms and the first consultation was 12.54 months with a median of 6 months. The most common form of presentation was balanoposthitis (32%) and the most common site in our series was the glans. Partial penectomy was performed in 22 cases, total amputation in 8, and local excision in 3. DISCUSSION: Carcinoma of the penis is a pathology which mostly affects elderly patients; in our series, the highest incidence was observed in patients in the group aged 75-84 years. The most common histological type was epidermoid carcinoma in its various forms of presentation. We recorded a mortality of 23%. CONCLUSION: Penile carcinoma is a rare pathology which affects elderly persons and is diagnosed late.

[Technics of ureteral endoscopic access]. / Técnicas de acceso endoscópico ureteral.

OBJECTIVES: The present article briefly reviews the history of endoscopic access to the ureter, since visualization of the ureter was first attempted until the procedure was developed by Pérez-Castro in 1979. METHODS/RESULTS: The development of the rigid ureteroscopes, the difficulties arising from the anatomical structures during endoscopy that require ureteral dilatation, the anatomy of the juxtavesical segment of the ureter and the pathologies that may alter it, and the present and future indications of ureteral dilatation are discussed. Patient preoperative evaluation is briefly described and one of the techniques of ureteral dilatation is analyzed. Finally, a brief summary comparing the different techniques is given. CONCLUSIONS: The technique of choice for ureteral dilatation must be simple, easy to perform, low-cost and one which reduces the iatrogenic lesions and shortens the duration of hospital stay.

[Triple ureter with inverted ureteral branch in "y" with ectopic ending and calculi inside]. / Triple uréter con rama ureteral en "y" invertida con desembocadura ectópica y litiasis en su interior.

OBJECTIVE: To report an uncommon case of ureteral duplication with a single intramural trajectory and a third ureter arising from the medial ureter, corresponding to the inferior pyelon, opening at the level of the bladder neck and containing a calculus measuring 10 mm along its longest axis, lodged in a saccular dilatation. The etiopathogenesis of this rare anomaly is briefly reviewed and discussed. METHODS/RESULTS: Diagnosis was established endoscopically and pyelographically. Endoscopic resolution was not possible, but stone removal was successfully achieved by conventional surgery using the least invasive approach possible. The patient is asymptomatic 24 months postoperatively. CONCLUSION: Although infrequent, this condition should be suspected in those "unclear' cases seen in day-to-day urological practice. Symptoms of the associated pathology are more common than those arising from the anomaly. Treatment should be specific to each case, as least invasive as possible and should aim at symptomatic resolution.

[Endourologic complication: endourologic resolution]. / Complicación endourológica: resolución endourológica.

OBJECTIVES: To report an uncommon endourological complication that was also resolved by endourological methods. METHODS/RESULTS: We report on a patient with a right solitary kidney, radiolucent renal stone and an indwelling double-J catheter. While removing the double-J catheter after ESWL, it broke at the level of its distal third. The proximal two thirds remaining in the ureter were successfully removed by ureteroscopy after several attempts by ureteroscopy and percutaneous nephroscopy. CONCLUSIONS: Except for special circumstances, most of the endourological complications can be resolved by an endourological procedure.

[Memotherm as a therapeutic device in infravesical obstruction]. / El Memotherm como medio terapéutico de la obstrucción infravesical.

OBJECTIVE: To determine the efficacy of the intraurethral mesh in the treatment of infravesical obstruction in patients at high surgical risk unamenable to other treatment modalities. METHODS: We evaluated 13 patients with obstruction and at high risk for conventional surgery (TURP) who underwent insertion of the Memotherm intraurethral prosthesis. RESULTS: The procedure was performed rapidly with scant morbidity and the patients were discharged from the hospital early. Improvement, evaluated by the IPSS-L, was referred by 84.6% of the patients at 45 weeks follow up. Post-treatment improvement was evidenced by the absence of postvoiding residual urine at ultrasound in 69.2% of the patients and improved flowmetry in 84.6% of the patients. The early post-treatment complications included hematuria with irritative symptoms (80% of the patients). The mesh prosthesis had migrated in 15%, but could be repositioned. No case required removal of the prosthesis. CONCLUSIONS: This method affords a rapid and atraumatic solution for obstructed patients at high surgical risk. The material (heat sensitive nitinol) and the design of the mesh facilitate repositioning in the few cases in whom this had been required.

[Extracorporeal shock wave lithotripsy (ESWL) in children: our experience in 1995]. / Litotricia extracorpórea por ondas de choque (ESWL) en niños: nuestra experiencia en 1.995.

OBJECTIVES: The present study reviews our experience and analyzes the results achieved with extracorporeal shock wave lithotripsy in the treatment of urinary calculi in children. METHODS: From 1985 to 1995, 36 children, with ages ranging from 5 months to 14 years, were treated by ESWL, and in some cases by combination therapy (percutaneous nepholithectomy and/or ureteroscopy). RESULTS: Excellent results were achieved in 74.9% of the patients; of these, 52.7% were stone-free 2 to 90 days after treatment. CONCLUSIONS: Extracorporeal shock wave lithotripsy is the treatment of choice in children with urinary lithiasis, although there are some exceptions. The method of evaluation and treatment in children are the same as in the adult patients.

[Clinical pathway for TUR of bladder neoplasms. Analysis of the first 2 years of its implementation]. / Vía clínica para la RTU de neoformaciones vesicales. Análisis de los 2 primeros años de implantación.

OBJECTIVE: To analyze the results of the first two years of application of the clinical pathway for transurethral resection (TUR) of bladder tumors at La Paz University Hospital. METHODS: We developed a clinical pathway of 4 hospital stays (5 days) for TUR of the bladder that included the following: matrix-verification, treatments prescribed, verification of changes, patient information sheet and patient satisfaction questionnaire. The information for the evaluation of the results were obtained from the pathway records and data on the activities of the Urology services. To assess the results for efficiency in the use of resources, the mean duration of hospital stay of patients in the pathway were compared with that of a control group comprised of 50 randomly selected patients submitted to TUR of the bladder in 1997. RESULTS: From June 1998 to May 2000, 481 of the 494 (97.4%) treated patients entered the clinical pathway. CONCLUSIONS: In our experience, the clinical pathway for the urinary bladder is a useful instrument for developing the clinical management of this condition. It reduces the unwanted changes in patient care and hospital stay, carries a low incidence of complications and readmissions, and achieves a high degree of patient satisfaction.

[Prognostic value of inverted papilloma of the lower urinary tract]. / Valor pronóstico del papiloma invertido del tracto urinario inferior.

OBJECTIVE: Inverted papilloma of the urothelium accounts for 2.2% of urothelial neoplasms. Its oncologic significance is unclear; its potential for recurrence and/or progression is not well-known. Our experience from 1976 to 1999 is reviewed. METHODS: From 1976 to 1999, 31 patients with urothelial inverted papilloma of the lower urinary tract have been treated in our service: 17 presented previous and/or synchronous association with urothelial carcinoma (group I) and 14 had primary inverted papilloma (group II). The recurrence and progression rates for each group were determined and compared. The overall recurrence and progression rates were also determined. Two patients (one from each group) were lost to follow-up. The remaining 29 patients had a mean follow-up of 51.3 months (range 3-125). RESULTS: 12 patients (41.4%) showed recurrence in the form of bladder carcinoma; 10 from group I (10/16; 62.3%) and 2 from group II (2/13; 15.4%) (p < 0.05). Mean time to recurrence was 17.9 months (range 3-58). Disease free interval was higher in group II (p < 0.05). Progression to infiltrating tumor was observed in three patients; all three had associated superficial bladder carcinoma (group I). The mean time to progression was 30.7 months (range 18-38). No statistically significant differences were found in the percentage of progression between both groups. CONCLUSIONS: Inverted papilloma of the lower urinary tract showed a high incidence of association with urothelial carcinoma and a high recurrence rate, even in primary tumors. Therefore it should be considered a tumor of low grade malignancy that should be followed regularly.

[Development of a clinical pathway for radical prostatectomy]. / Implantación de una vía clínica para la prostatectomía radical.

OBJECTIVE: To describe the clinical care path for retropubic radical prostatectomy of the La Paz teaching hospital and the results achieved after the first 6 months. METHODS: We have developed a clinical care path for radical prostatectomy with a hospital stay of 6 days. Thirty-one patients submitted to retropubic radical prostatectomy from June to November 1998 were included in the program. The mean length of total, preoperative and postoperative stay were analyzed and compared with those of 31 patients who had undergone radical prostatectomy before the program was developed. Readmissions, adverse effects and patient satisfaction were also analyzed. RESULTS: Of the 31 patients included in the clinical care path, 22 (71%) had a stay equal to or less than the program's length of stay. The mean total, pre and postoperative stay for the group of patients included in the clinical care path were 6.0 days (SD = 1.1), 1 day (SD = 0.0) and 4.9 days (SD = 1.1), respectively. The length of stay was significantly longer before the program was developed [mean total 10.2 days (SD = 4.9), mean preoperative 2.6 days (SD = 2.6) and mean postoperative 7.6 days (SD = 3.6)] (p < 0.001). Twenty-four patients (77.4%) completed the questionnaire on patient satisfaction, which was highly positive, the overall patient satisfaction rate being higher than the 90% standard. There were no readmissions or significant events ascribable to the program. CONCLUSIONS: In our experience, the clinical care path for radical prostatectomy is a useful tool to reduce the unwanted variability. Its design is based on the best possible evidence, therefore the scientific and technical quality, patient satisfaction and efficiency are enhanced. In our view, our results are attainable and feasible in any health care setting.