[Dr. Luis Cifuentes Delatte: clinician, surgeon and researcher]. / Do Luis Cifuentes Delatte, Do Luis: clinico, cirujano e investigador.

The author, disciple of Dr. Cifuentes, thinks about the influence and teaching of his professor emphasizing some features that specially marked us. We emphasize his capacity to observe reality, his meticulous reading of all tests, his analysis of all the information obtained, and his intellectual rigor in the elaboration of the diagnosis. His interest for the patient, his thoughts about bladder cancer or the importance of statistics, and the introduction and support of endoscopic surgery in Spain are outstanding features. It is also outstanding his defense of urology as a medical-surgical specialty. As a conclusion we have his best legacy: his thoughts, his books and scientific works.

[The role of transrectal ultrasound on prostatic cryotherapy and brachytherapy]. / Papel de la ecografía transrectal en crioterapia y braquiterapia prostáticas.

OBJECTIVES: Transrectal ultrasound is the method that gives a direct image of the prostate, its limits, structural and morphologic anomalies, and anatomical relations. Therefore, prostate volume is easily determined, being the first step for the application of certain therapeutic procedures. Prostatic cryotherapy and brachytherapy have been developed over the last years as minimally invasive options for the treatment of prostate cancer. Transrectal ultrasound of the prostate has allowed the application of these technologies in the daily practice, guaranteeing high efficacy and safety indexes. Cryosurgery is the controlled freezing of tissues. Prostatic transrectal ultrasound is the only method able to show the real-time evolution of prostatic cryoablation, allowing the urologist to control the evolution of the ice ball and to reach the targeted anatomical structures guaranteeing the oncological objectives, and diminishing complications and sequels. Brachytherapy, as a local intraprostatic radiotherapy, needs exact volume and dose calculations before the implant of the radioactive source within the gland. With transrectal ultrasound of the prostate, ultrasound-tomographic cuts are made for prostatic volume calculation and planimetry Once dosimetry is completed, real-time transrectal ultrasound control is necessary to perform the implant of the needles loaded with the seeds. Today, prostate cryotherapy and brachytherapy would be inconceivable without transrectal ultrasound.

[Cryotherapy III, bibliographic review. Our experience(II)]. / Criocirugía (tercera parte). Revisión de la literatura y nuestra experiencia. (II).

OBJECTIVES: To perform a bibliographic review of the main features of cryotherapy as a therapeutic option in the monagemente of prostate cancer and to report our initial experience. METHODS: We employed the Endocare Fast-Trac system (Medipro) with 2.4 mm needles implanted in a single maneouvre without rack or transrectal U.S. transducer support. Two cycles of freezing thawing were employed, with apex backward movement when necessary. Freezing cycle duration was between 7-10 minutes or more. The Onik maneouvre--injection of saline into the Denonvillier's space-diminishes the risk of rectal injury and fistula allowing reaching posterior limits of the icaball beyond the prostatic capsule. RESULTS: We treated 20 patients. Follow-up was between 3036 months. 58% of the patients had unilateral prostate cancer, 42% bilateral. In accordance to the classic definition 9 patients were classified as low risk of extraprostatic disease, 6 medium risk and 5 high risk; using number of positive cores as the criterion for risk 5, 6 and 9 were low, medium and high risk respectively. Per protocol prostate biopsies were performed in 18 patients 6, 12 and 24 months after treatment. Two patients underwent a second treatment due to persistence of cancer cells in the 6-month biopsy (11%). 3-month PSA nadirs after a total of 21 cryo treatments administered were < 0,2 ng/cc in 15 cases (78.9%), < 0.5 ng/cc in 17 (89.4%) and < or = 1.0 ng/cc in 18 (94.7%); it was over 1 ng/cc in only 5.6%. 30 month PSA for the same cutoff values was 27.8%, 50.0%, 66.6% and 33.3%, respectively. Prostate cancer cells were detected in the 12-month biopsies of 5.5% cases. All 24-month biopsies were negative. COMPLICATIONS: We observed scrotal edema, hematoma, perineal pain and constipation which lasted 2-3 weeks. 1 patient suffered injury of the mucosa at the prostatic urethra, which did not result in rectal fistula and was treated with bladder catheter for 3 months. 4 patients had erectile dysfunction before treatment. All others presented erectile dysfunction after treatment; 3 of them (20%) recovered rigidity enough to have intercourse over the 30 month period. No urethral sloughing or acute urinary retention appeared and all patients are continent. CONCLUSIONS: Prostatic cryosurgery is an effective, minimally invasive procedure for the treatment of prostate cancer with very low surgical risk, low morbidity and almost null mortality.

[Cryotherapy III, Bibliographic review. Our experience (I)]. / Criocirugía (tercera parte). Revisión de la literatura y nuestra experiencia. (I).

OBJECTIVES: To perform a bibliographic review of the main features of cryotherapy as a therapeutic option in the managemente of prostate cancer and to report our initial experience. METHODS: We employed the Endocare Fast-Trac system (Medipro) with 2,4 mm needles implanted in a single maneouvre without rack or transrectal US transducer support. Two cycles of freezing--hawing were employed, with apex backward movement when necessary. Freezing cycle duration was between 7-10 minutes or more. The Onik maneouvre-injection of saline into the Denonvillier's space--diminishes the risk of rectal injury and fistula allowing reaching posterior limits of the ica-ball beyond the prostatic capsule. RESULTS: We treated 20 patients. Follow-up was between 30-36 months. 58% of the patients had unilateral prostate cancer, 42% bilateral. In accordance to the classic definition 9 patients were classified as low risk of extraprostatic disease, 6 medium risk and 5 high risk; using number of positive cores as the criterion for risk 5, 6 and 9 were low, medium and high risk respectively. Per protocol prostate biopsies were performed in 18 patients 6, 12 and 24 months after treatment. Two patients underwent a second treatment due to persistence of cancer cells in the 6-month biopsy (11%). 3-month PSA nadirs after a total of 21 cryo treatments administered were < 0,2 ng/cc in 15 cases (78,9%), < 0,5 ng/cc in 17 (89,4%) and < or = 1.0 ng/cc in 18 (94,7%); it was over 1 ng/cc in only 5,6%. 30 month PSA for the same cutoff values was 27.8%, 50.0%, 66.6% and 33.3%, respectively. Prostate cancer cells were detected in the 12-month biopsies of 5.5% cases. All 24-month biopsies were negative. COMPLICATIONS: We observed scrotal edema, hematoma, perineal pain and constipation which lasted 2-3 weeks. 1 patient suffered injury of the mucosa at the prostatic urethra, which did not result in rectal fistula and was treated with bladder catheter for 3 months. 4 patients had erectile dysfunction before treatment. All others presented erectile dysfunction after treatment; 3 of them (20%) recovered rigidity enough to have intercourse over the 30 month period. No urethral sloughing or acute urinary retention appeared and all patients are continent. CONCLUSIONS: Prostatic cryosurgery is an effective, minimally invasive procedure for the treatment of prostate cancer with very low surgical risk, low morbidity and almost null mortality.

[Technical principles of prostatic cryosurgery (Part 1)]. / Principios técnicos de la criocirugía prostática. (1a Parte).

OBJECTIVES: Cryosurgery is defined as in situ freezing of tissues. Criosurgery in the treatment of prostate cancer aims to: 1- Eliminate all the glandular tissues and completely destroy the adenocarcinoma, 2- With a minimum number of complications. a) Preserving neighbour structures: bladder neck, striated sphincter, and rectum. b) Preserving urethral mucosa to reduce the elimination of sloughing tissues. METHODS: We describe the technique of prostatic cryosurgery including all innovations introduced during the last ten years. The map with the number and situation of the 6-8 crioprobes should be done in such a way that the iceball created around each of them overlaps the contiguous ones. Probe-mapping and icing strategy together get the prostate included in a unique, solid mass, in which temperature descents homogeneously and spreads out of its limits, so that intraprostatic and extraprostatic temperatures (sensors at the apex, Denonvilliers fascia and both neurovascular bundles) are below -40 degrees C. RESULTS: The standardized technique is based on: Substitution of liquid nitrogen by argon. Use of 6 to 8 cryoprobes. The probes are properly inserted into the perineum percutaneously under transrectal ultrasound guidance. Ice ball evolution control by biplane transrectal ultrasound. Separation of the two layers of Denonvilliers' fascia by injection of saline solution. Real-time measurement of temperature descent. Minimal temperature lower than -40 degrees C Commercial ureteral heating system. Double cycle of freezing-unfreezing Administration of hormonal therapy during time enough to avoid the gland size to exceed 45-50 cc. CONCLUSIONS: We describe the most advanced technique for prostatic freezing, highlighting the basic requirements to achieve the objectives pursued. It has improved oncologic results, in relation to PSA and percentage of negative biopsies, and has dramatically reduced complications.

[Treatment of upper urinary tract tumors. Report of our experience]. / Tratamiento de los tumores del tracto urinario superior. Aportación de nuestra experiencia.

OBJECTIVES: The objective of this article is to perform a comprehensive exposition of the various non-endourological treatment options for upper urinary tract tumors in order to set the bases to choose the most adequate surgical indication depending on tumors' and patients' characteristics; we consider the various surgical approaches, and the historic evolution from the classic indication established by Albarran (radical nephroureterectomy with bladder cuff) to the current ones more conservative. We also consider the role of radiotherapy and chemotherapy in the treatment of these tumors. METHODS/RESULTS: We refer to the conclusions of various authors and their large series published in the literature, series considered classic already, and provide support adding our experience by reviewing 223 patients treated from 1977 to 2003 with a mean follow-up of 45 months (maximum 238 months). CONCLUSIONS: We can state that it is acceptable to indicate less aggressive ways of treatment (nephroureterectomy without bladder cuff, distal or partial ureterectomy, and conservative operations) if the oncological radicality requirements are met, remembering that site, tumor grade and stage are determinant in the outcome.

[Recurrent spontaneous bladder rupture associated with alcohol abuse: presentation of a new case]. / Ruptura espontánea vesical recidivante asociada a abuso de alcohol: presentación de un nuevo caso.

OBJECTIVE: Idiopathic spontaneous bladder rupture is a low incidence clinical entity. We perform a literature review and report a recurrent case, with special attention to its physiopathology mainly if associated with alcohol abuse. METHODS: We report the case of a patient with recurrent spontaneous bladder rupture associated with alcohol abuse. The presentation of this case is uncommon. RESULTS: 53 year old male with history of chronic alcohol abuse who presented with abdominal pain and renal failure. CONCLUSIONS: Spontaneous bladder rupture is the cause of acute abdomen and acute renal failure. Idiopathic rupture associated with substance abuse has proper clinical characteristics that make it to be considered a different entity than other causes of spontaneous bladder rupture.

[Cryobiology and pathologic lesions induced by freezing-thawing processes in prostatic tissue. Second part]. / Criobiología y lesiones anatomopatológicas inducidas por la congelación-deshielo en el tejido prostático. 2a Parte.

Cryosurgery is an emerging technology consisting on controlled freezing of tissues. Good results, maintained in the long-term, have been referred in the treatment of prostate adenocarcinoma. A role as possible substitute of partial nephrectomy in the treatment of renal adenocarcinomas smaller than 4-5 cm is under research. There is no discussion that freezing destroys cellular machinery and triggers several events the final result of which is cell death by necrosis and apoptosis. The decrease of temperature makes extracellular liquid crystallize and creates a hyperosmotic environment, which induces water to go out of the cell producing intracellular dehydration. Intracellular ice is created with fast freezing speeds being attributed the most destructive effect on biological tissues with irreparable damage. In blood vessels, it directly induces endothelial cell death and mechanical lesions of the endothelium; the consequence is the formation of thrombi that obstruct the lumen of the vessel. In the post-thawing phase there is an increase in free radicals formation and neutrophil activity, which induces cellular membrane lipids peroxidation and new endothelium lesions. Tissue destruction is determined by: minimal temperature achieved, freezing speeds, freezing phase duration, number of freezing-thawing cycles provided, and distance to the freezing focus. As we move away from the freezing focus cells are affected in different ways, and there are several mechanisms proposed to explain the lethal action induced by temperatures higher than--40 degrees C. In our series pathologic findings were: necrosis, hemorrhagic areas either developed or not, fibrosis, hyalinization and increases in the relative number of hematic capillaries, microscopic calcifications, basal cells hyperplasia, and transitional or squamous metaplasia. Residual cancer is localized in the areas less affected by freezing. It should be emphasize the scarce morbimortality associated with the procedure. It does not require ICU admission or blood transfusions, no cerebral vascular accidents (CVA) or heart events have been described, and mortality is null, so that it is feasible in high surgical risk patients and without age limit.

[Penile metastasis of a prostatic adenocarcinoma]. / Metástasis peneana de adenocarcinoma prostático.

OBJECTIVES: To report one case of prostate carcinoma with metastasis to the corpora cavernosum. METHODS: We report the case of a 79-year-old patient with the diagnosis of Gleason 9 prostatic adenocarcinoma who presented a hard lesion on the glans penis one year after starting androgen blockade. The patient underwent palliative TURP and biopsy of the lesion. RESULTS: Pathology reported a penile metastasis of prostatic adenocarcinoma. CONCLUSIONS: Penile metastasis are rare, usually appearing in advanced stages of the primary disease; their treatment is palliative and should only be carried out in symptomatic patients.

[Infertility and varicocele through history]. / La infertilidad y el varicocele a través de la historia.

OBJECTIVES: To perform a historical review of varicocele and male infertility with the aim to find descriptions that first related them. In parallel, we review the evolution of treatment for varicocele up to date. METHODS/RESULTS: We refer to multiple authors and their treaties on Medicine, from first to 20th Century, in which descriptions of these pathologies are found, focusing on descriptions of the surgical technique for treatment of varicocele and their application in Spain. CONCLUSIONS: Varicocele was already described in treaties from the first century having bee of n its treatment predominantly surgical from the first description to our days. Not identified as a cause of infertility until late, by the end of the 19th century, it is the main indication for treatment nowadays. The surgical technique has suffered many modifications over time, both in the approach as in the "radicality" of a vascular ligature applied.

[Hypogastric artery embolization as a palliative treatment for bleeding secondary to intractable bladder or prostate disease]. / Embolización de arterias hipogástricas como tratamiento paliativo del sangrado secundario a enfermedad vesical o prostática intratable.

OBJECTIVES: Bleeding secondary to severe vesicoprostatic pathology (mainly neoplasic disease and radiation cystitis) may be a serious clinical management problem due to its morbidity and associated increased resources demand in the form of admissions, transfusions and other measures. We review a series of patients embolized for this purpose, its efficacy, tolerability and adverse events. METHODS: We review 8 patients who underwent hypogastric arteries embolization between July 1998 and December 2001, analyzing indications, efficacy and duration, tolerability, and consequences. Right femoral artery access was undertaken in all except one case that needed bilateral femoral accesses. Embolization was achieved by means of coils and particles. All procedures were performed under local anaesthesia. RESULTS: 9 procedures were performed in 8 patients. 3 patients presented with hematuria due to radiation cystitis, 3 from prostatic carcinoma, and 2 with urethrorragy from urethral relapses after cystectomy. 7/9 embolizations were effective achieving immediate complete or almost complete bleeding control; in one case control was partial; another one had limited or no effect. Selective embolization of distal arteries was performed in 3 cases; all the remainders underwent direct hypogastric trunk embolization sparing the superior gluteal artery. Effect lasted between 1 and 31 months. 4 patients died, 3 of them without haematuria, 1 because of an intercurrent disease, and the others from disease progression. 2 patients underwent posterior surgery, one due to recurrent haematuria, and the other, a case of urethral tumour, due to partial failure; partial cystectomy and urethrectomy were performed respectively. 2 patients needed administration of morphic derivatives after embolization, all the others were managed with magnesium metamizol. Only one patient referred mild transitory gluteal claudication. CONCLUSIONS: Percutaneous arterial embolization is an effective instrument to treat patients with haematuria or urethrorragy and severe lower urinary tract pathology in whom curative treatments are not applicable due to their general status, life expectancy, or tumor status.

[Adrenal cysts: presentation of 6 cases]. / Quistes suprarrenales: presentación de seis casos.

OBJECTIVES: We report six cases of adrenal cyst, a rare pathologic entity which poses diagnostic problems and therapeutic controversies. METHODS: We report six cases of adrenal cysts in 4 female and 2 male patients ages 26 to 68 years. All cases underwent surgical treatment. RESULTS: Pathologic studies showed that all were adrenal cysts without malignancy in any case. CONCLUSIONS: Adrenal cysts are a rare disease of which correct diagnosis is difficult so that many times patients undergo surgery without a proper preoperative diagnosis. There are controversies about the right management of adrenal cysts.

[AMS-800 artificial sphincter. Our experience in the last 20 years]. / Esfinter artificial AMS-800. Nuestra experiencia en los últimos 20 años.

OBJECTIVE: To present a series of 63 patients with urinary incontinence due to sphincteric incompetence who underwent the implantation of an AMS-800 artificial sphincter. METHODS: From 1984 to December 2002 a total of 69 patients received this prosthesis, 63 of which were available for review. The cause of incontinence was sphincter incompetence in all cases, said secondary to prostate surgery, neurogenic bladder, post-traumatic urethral lesion, and epispadias. 52 of them were placed in the bulbar urethra, and 11 in the bladder neck. The cuff diameters varied from 4 to 10 cm and reservoir pressures from 51-60 to 71-18 H2O cm. RESULTS: The complications that appeared, ordered by frequency, were: malfunction, infection and rejection or exteriorization, fistula, and unappropriate size. The total number of reoperations was 39 in 28 patients. Functional results were successful in 48 cases and failure in 15. CONCLUSIONS: The use of an AMS-800 prosthesis for the treatment of urinary incontinence due to sphincteric incompetence is effective but not without complications. The most frequent indication was following prostate surgery, being this group the one that obtains the best results. Patients with incontinence of neurogenic origin have the highest complication rate, and the worst results in relation to vascularization and tissue trophism abnormalities. In female patients we prefer other techniques that have similar results, are technically easier and more economic.

[Acute obstructive kidney failure after kidney transplantation caused by calculi transfer from donor]. / Fracaso renal agudo obstructivo post-trasplante renal por trasferencia litiásica desde el donante.

OBJECTIVES: To report one case of lithiasis transference from the donor associated with renal transplant. METHODS: 53-year-old female with obstructive uropathy within the first post transplant month. RESULTS/CONCLUSIONS: Lithiasis transference after transplant is a cause of early obstructive uropathy after kidney transplantation. The low the incidence of lithiasis transference does not justify the performance of x-ray and/or ultrasound of the donor organ in terms of cost effectiveness. Extracorporeal shockwave lithotripsy is a valid therapeutic option on transplanted kidneys.

[Acute renal failure as the beginning of glandular cystitis. Review of the bibliography]. / Fracaso renal agudo como debut de la cistitis glandular. Revisión de la bibliografía.

OBJECTIVES: To report one clinical case of obstructive uropathy secondary to bladder pseudotumor. METHODS: We report the case of a 74-year-old male with obstructive acute renal failure of unknown etiology. RESULTS: After resolution of the acute renal failure by percutaneous nephrostomy, action was undertaken to control possible etiologic causes, resolving the bilateral ureter entrapment and bladder inflammatory process. CONCLUSIONS: Glandular cystitis is a nosological entity which in its severe forms behaves clinically and radiologically as a bladder pseudotumor, so that should be considered as a part of the differential diagnosis with bladder tumors. Final diagnosis comes from pathology. For treatment, it is basic to eliminate any predisposing factor, either infectious, or irritative, or obstructive; if no action is carried out on these factors other therapeutic measures as the aforementioned are not effective. Strict follow-up should be undertaken (every six months) because of the high incidence of bladder adenocarcinoma.

[Current status of high-resolution scrotal echography]. / Estado actual de la ecografia escrotal de alta resolución.

OBJECTIVES: To review the main images that can be observed by ultrasound, trying to highlight what decision to take after their finding: exploratory surgery, orchyectomy, or follow-up. METHODS: We performed a bibliographic review about the topic and incorporated our personal experience with scrotal ultrasound. Given that there is an extensive variety of anomalies that can be observed we divide them in liquid and solid lesions, and these in intra or extratesticular, plus a group of lesions that do not qualify in the previous groups. RESULTS: The development of high frequencies transducers (8-10 Mhz) and a greater experience today allows to diagnose not only testicular tumors but also a number of benign clinical entities, with enough specificity in some of them as to avoid surgery. CONCLUSIONS: Ultrasound is a simple test, painless, and can be repeated without trouble, so that it is the first test that should be ordered when managing any intra scrotal problem.

[Extrarenal retroperitoneal angiomyolipoma: bibliography review and report of a new case]. / Angiomiolipoma pararrenal: "revisión de la bibliografía" y presentación de un nuevo caso.

OBJECTIVES: To report the 7th case of pararenal angiomyolipoma published in the world literature and to review the international bibliography. METHODS: We report the case of a 46-year-old female with history of renal colic and a complex mass on radiological tests. RESULTS/CONCLUSIONS: Extrarenal retroperitoneal angiomyolipoma is a rare pathology with no more than 7 published cases. The diagnostic difficulty and radiological similarities with liposarcoma make surgery the treatment of choice.