Giant adrenal carcinoma associated with renal vein and inferior vena cava thrombus. Case report and literature review.

OBJECTIVE: To present a case of giant adrenal carcinoma associated with renal vein and inferior vena cava (IVC) thrombus. Up to now, there is no similar case reported in the national literature. METHODS: 75 year old woman with signs of virilization. CT-scan showed an 18 cm adrenal mass with venous thrombus and possible pulmonary metastases. The working diagnosis was primary suprarenal carcinoma. RESULT: Due to elderly age and advanced stage, including metastasis, we decided to not perform surgery, and initiate chemotherapy. CONCLUSIONS: Adrenal Cancer is an infrequent and very aggressive tumor. Surgery is the only curative treatment. In advanced stages chemotherapy is recommended, but with poor results.

Evaluation of teleconsultation system in the urological patient during the COVID-19 pandemic. / Evaluación de la teleconsulta en el paciente urológico durante la pandemia COVID-19.

INTRODUCTION: The global pandemic of COVID-19 has led to rapid implementation of telemedicine, but there is little information on patient satisfaction of this system as an alternative to face-to-face care. OBJECTIVE: To evaluate urological patient satisfaction with teleconsultation during the COVID-19 pandemic. MATERIAL AND METHODS: Observational, prospective, cross-sectional, non-interventional study carried out by telephone survey during the period considered as the peak of the pandemic (March-April 2020). A quality survey composed of 11 questions on urological care provided by physicians during the COVID-19 pandemic was conducted, selecting a representative sample of patients attended by teleconsultation. RESULTS: Two hundred patients were contacted by telephone to answer a survey on the quality of teleconsultation. The distribution of patients surveyed among the specialized consultations was homogeneous with the number of consultations cited in the period; 18% of them required assistance from family members. Sixty percent of patients avoided going to a medical center during the pandemic. Of the surveyed patients, 42% had cancelled diagnostic tests, 59% had cancelled medical consultations, 3.5% had cancelled treatments and 1% had cancelled interventions. Ten percent reported a worsening of urological symptoms during confinement. According to physicians, consultations were effectively delivered in 72% of cases, with teleconsultation being carried out by their usual urologist in 81%. Teleconsultation overall satisfaction level was 9 (IQI8-10), and 61.5% of respondents consider teleconsultation as a «health care option¼ after the healthcare crisis. CONCLUSION: Teleconsultation has been evaluated with a high level of satisfaction during the COVID-19 pandemic, offering continuous care to urological patients during the healthcare crisis. The perceived quality offers a field of optional telematic assistance in selected patients, which should be re-evaluated in a period without confinement measures.

A new approach to laparoscopic implantation of the artificial urinary sphincter: Vesicovaginal approach to the bladder neck. / Nueva aproximación al implante laparoscópico del esfínter urinario artificial: abordaje vesicovaginal al cuello vesical.

INTRODUCTION: The artificial urinary sphincter (AUS) is not used extensively in the treatment of female urinary stress incontinence (USI) due to the poor reproducibility of the techniques used. We describe a new approach to laparascopic implantation, of which dissection of the vesicovaginal space is an essential step. This enables an approach under direct vision to the posterior surface of the bladder neck. MATERIAL AND METHODS: We present two cases where this approach was used. A transperitoneal approach was made in the Trendelenburg position. The main steps were: creating the vesicovaginal space until identifying the bladder neck, creating two laterovesical spaces, communicating these with the vesicovaginal space, and dissecting the anterior surface of the bladder neck, attempting to preserve the pubovesical ligament. The cuff and reservoir were inserted through the 12mm infraumbilical trocar. The connections were externalised through a left suprapubic incision and a subcutaneous tunnel created up to the labia majora where the activation pump was placed. The procedure was completed with closure of the peritoneum. It is essential to use a vaginal valve to facilitate dissection. RESULTS: Surgery time: 140 and 135minutes, with no intraoperative complications. After removing the urinary catheter, one patient had elevated postvoid residual urine volume, which was managed conservatively. Hospital stay: 72h. At 3 and 9 months the patients were fully continent. CONCLUSIONS: We present the preliminary results of laparoscopic implantation of an AUS through a vesicovaginal approach to the posterior surface of the bladder neck, which might reduce potential complications that have been observed after the routine techniques.

[Shattered kidney in a patient with asymptomatic chronic hydronephrosis. Case report and literature review]. / Estallido renal en paciente con hidronefrosis crónica asintomática. A propósito de un caso y revisión de la literatura.

The incidence of renal anomalies in patients who suffer a renal trauma is around 4.4 and 19%. We introduce a case of a patient whose first sign of a chronic hydronefrosis was a renal burst secondary to an abdominal trauma.

[Left inferior vena cava with renal cell carcinoma]. / Vena cava renal izquierda en un paciente con carcinoma de células renales.

We presented a case of inferior vena cava on the left side diagnosed by abdominal CT scan during the study of a renal cell carcinoma in the right side. This anomaly is very rare but it may suppose a more difficult approach to the nephrectomy.

Cost-effectiveness analysis of main diagnosis tools in women with overactive bladder. Clinical history, micturition diary and urodynamic study.

OBJECTIVES: The aim of the present clinical research is to analyze, in the light of the best scientific evidence, the performance and the cost of the main diagnostic tools for overactive bladder (OAB). METHODS: It is an exploratory transversal study in which 199 women diagnosed of OAB between 2006 and 2008 were selected and underwent to following prospective analyses: physical examination, urine analysis, micturition diary (MD) and urodynamic study (UDS). A percentage of 80% was assumed as highly sensitive and a diagnostic difference among tests of 10% would be considered clinically relevant. Tests' sensitivity for diagnosis of OAB was statistically established by two ways: isolated and combined. Besides, the direct and indirect costs of these tests performance were conducted. Cost-effectiveness study of clinical history (CH), MD and US for the diagnosis of OAB was performed. RESULTS: Overall sensitivity for OAB diagnosis is low for the 3 tests used in isolated way, whilst the combination of any two tests shows good overall sensitivity. The combination of CH and MD has appeared as the most cost-effective alternative to OAB diagnosis. CONCLUSIONS: For OAB diagnosis, CH-DM combination shows the same sensitivity than the association of either of them with the UDS, but unlike to these, it shows the lowest cost.

[Differential traits of prostatic cancer detected through an early screening program versus the one detected during urologic consultation]. / Rasgos diferenciales del cáncer de próstata procedente de un programa de detección precoz frente al detectado en una consulta de urología.

OBJECTIVE: To compare some features of prostate cancers (PCa) detected in a screening program, versus cancers diagnosed in an outpatient clinic. MATERIAL AND METHODS: Retrospective study of 393 patients with biopsy evidence of PCa: 93 (23.7%) from a screening campaign, and 300 (76.3%) detected in an outpatient Urology clinic. Features studied at the moment of diagnosis were age, PSA, digital rectal examination (DRE), transrectal ultrasound (TRUS) characteristics and volume stimation, PSA density (PSAD), clinical stage and Gleason score. A comparison was established between the two groups of patients taking into account the mentioned parameters. RESULTS: A higher age, PSA and DPSA values were found among cancers detected out of the screening program. A greater probability of abnormal DRE and a more advanced clinical stage was also noted. In the screening group, 78.5% of the cancers were localized and 8.6% metastatic. In the outpatient clinic group, the proportions were 50.7% and 26%, respectively. No differences were found with respect to TRUS findings, prostate volume, or Gleason score. CONCLUSIONS: Cancers detected in screening programs are found in earlier stages. Nevertheless, results from long term randomized studies are necessary to verify if these data really mean that a disease-specific mortality reduction can be achieved.

[Surgical treatment of stress urinary incontinence in our setting: analysis of results]. / Tratamiento quirúrgico de la incontinencia urinaria de esfuerzo en nuestro medio: análisis de resultados.

INTRODUCTION AND OBJECTIVE: Surgical repair is the most effective option for the treatment of stress urinary incontinence (SUI) between the different therapeutical options available at present. The main objective of our study is to compare the outcome of the different techniques employed in the treatment of SUI in our setting. METHOD: We have performed a retrospective analysis of the patients who underwent surgical intervention for SUI between 1991 to 1999 (213 surgical interventions in 194 patients) clustering the surgical procedures into three groups: abdominal, abdomino-vaginal, and sling procedures. The results of the treatment were defined as follows: total continence, significant improvement and insufficient improvement. Comparison of continence rates was performed with chi 2 test and Fisher's exact test. Association between qualitative variables was also evaluated by means of chi 2 test. Multivariate analysis of predictive factors was performed with a Cox model. The outcome was also evaluated by Kaplan-Meier's curves, and comparisons made with log-rank test. Statistical significance level was established for p < 0.05. RESULTS: Global cure rate at 24 months was 54.5% (116 patients). Significant improvement was observed in 33 patients (15.5%), and insufficient improvement was seen in 64 patients (30%). The most frequent postoperative complications were suprapubic pain (33%), acute urinary retention (26%), significant postvoiding residual urine (24%) and wound seroma or infection (20%). None of the analyzed factors (age, weight, number of births, preoperative pads, postoperative acute urinary retention, and need for postoperative bladder clean intermittent catheterization were independent predictive factors for postoperative continence. The actuarial analysis with Kaplan-Meier curves shows no statistical differences between the studied techniques (log rank p = 0.41). Sling techniques presented with a superior rate of most postoperative complications. CONCLUSIONS: The cure rate of our serie was 54.5% at 24 months, with a 70% of clinically satisfactory responses. With regard to continence status, it seems that there is not a better surgical technique in our hands, presenting sling techniques with a higher rate of postoperative complications. We could not find no pre o postoperative independent factors as predictors of postoperative continence.

[Epidemiologic analysis of clear cell and chromophilic carcinoma of the kidney]. / Análisis epidemiológico del carcinoma renal de células claras y cromofílico.

OBJECTIVE: Finding differences in the characteristics of the two most frequent variants of renal cancers: the clear-cell renal carcinoma, and the chromophilic one. MATERIAL AND METHODS: Retrospective analysis of epidemiological characteristics of patients diagnosed of renal carcinoma in our hospital between 1991 and 2001. Statistical differences were searched between patients' characteristics (age, sex, smoking habitus) and tumors' characteristics (size, focality, stage, side and grade). RESULTS: Sixty six renal tumors were diagnosed, of which 41 (62.1%) were clear-cell tumors and 9 (13%) were chromophilic. We only found statistical differences between both subpopulations' tumor size (p < 0.05), being greater for clear-cell tumors (7 +/- 3.92 cm) than for chromophilic ones (4.89 +/- 1.96 cm). We could also appreciate a bias towards a less advanced stage of the chromophilic type, although not statistically significant. CONCLUSIONS: Clear-cell renal carcinoma and chromophilic renal carcinoma are the two more frequent variants of renal tumors. The chromophilic type is smaller and is usually found in a less advanced stage, although this bias could not be demonstrated in our series.

[The natural history of sperm cleareance after vasectomy]. / La historia natural del aclaramiento de espermatozoides en el semen tras la vasectomía.

OBJECTIVE: To study the time required to obtain a negative sperm analysis after vasectomy. MATERIAL AND METHODS: We reviewed 239 consecutive vasectomies performed between september 1998 and september 1999. All of them were done in an ambulatory basis. Follow up interval was 41-853 days (mean 144, median 104). The first semen analysis was requested between 1 and 6 months after the surgical procedure. If the sample still showed spermatozoa, then a new one was requested every two months. Probability of becoming azoospermic was studied with Kaplan-Meier curves. RESULTS: Persistent spermatozoa could be found in 31 patients (13%) at the end of follow-up. Despite having a positive semen analysis, 10 patients (4.2%) discontinued medical visits. Time required to obtain a negative sperm count ranged from 58 to 362 days (mean 133, median 99). The probability of being azoospermic 200 and 260 days after vasectomy was 80-90% respectively. A total of 328 semen analysis were requested (range 1-4, mean 1.37, median 1) CONCLUSIONS: A minimum of 200 days (6.6 months) are needed to clear all the spermatozoa in semen after vasectomy in 80% of our patients. Requesting the first semen sample 7 months after vasectomy is cost-effective, reducing unnecesary medical visits and increasing the rentability of this test.

[Adverse effects of transrectal prostatic biopsy. Analysis of 303 procedures]. / Efectos adversos de la biopsia prostática transrectal. Un análisis de 303 procedimientos.

INTRODUCTION AND OBJECTIVE: Prostate biopsy is a basic step towards prostate cancer (Pca) diagnosis, but usually not free from complications. In this article we have reviewed the adverse effects of this procedure in our setting. MATERIAL AND METHODS: We studied in a prospective fashion the complications arising from transrectal prostate biopsy with the aid of a questionnaire fulfilled by 303 patients who underwent this procedure, within the context of a Pca screening program. All biopsies were transrectal ultrasound guided and randomly taken (sextant). A cleaning enema was applied the night before, and 100 mg of intramuscular tobramycin were administered prior of the procedure. RESULTS: Ninety patients (29.7%) had no adverse effects at all, and 136 (44.9%) reported at least one minor complication (hematuria, hemospermia, or autolimited dysuria). Lastly 77 (25.4%) presented with major complications--urinary retention, fever, need for medical assistance (primary or hospital care) or treatment. Thirty-five patients (11.5%) reported to present with fever after biopsy, 145 (47.8%) hematuria, 95 (31.3%) hemospermia, 77 (25.4%) rectal bleeding, 67 (22.1%) urinary difficulty, and 9 (2.9%) urinary retention. Up to 39 (12.8%) needed to visit their G.P., and 19 of them were referred to Hospital, where only 6 (1.9%) were admitted longer than 24 hours. No intensive care unit admittances or deaths were reported. CONCLUSIONS: The rate of post-transrectal biopsy adverse effects is high in our experience. This phenomenon could be explained, in part, due to data collecting by means of a self-administered questionnaire. Probably the high fever rate presented here could be diminished with other type of antibiotic prophylaxis.

[Detection of prostatic cancer in the PSA range between 3 and 3.9 ng/ml]. / Deteccion del cáncer de próstata en el rango de PSA entre 3 y 3,9 ng/ml.

OBJECTIVE: In our study, we analyze the benefit of lowering the PSA cutoff point for which a prostate biopsy is indicated from 4 to 3 ng/ml. MATERIALS AND METHODS: We have considered 4.278 individuals coming from a prostate cancer screening program. We studied 1.217 interventions in which PSA was determined, indicating the prostate biopsy with PSA > or = 3 ng/ml. Digital rectal examination was never the indication for the biopsy. All biopsies were sextant and assisted by transrectal ultrasound. We compared the performance of the biopsy using 4 and 3 ng/ml as cut points. RESULTS: Of the 1.217 interventions performed, 947 had PSA values lower than 3 ng/ml, 80 between 3 and 3.9 ng/ml and 190 over 4 ng/ml. A total of 189 patients (70% of these two last groups) underwent a prostate biopsy. With 4 ng/ml as the cut point, 134 biopsies were indicated, detecting 28 cancers (positive predictive value 20.9%). However 189 biopsies were indicated and 34 cancers detected by lowering the cut point to 3 ng/ml (positive predictive value 17.9%). The reduction in the biopsy performance was not statistically significant (OR = 0.89). None of the 6 additional cancers detected was palpable or ecographically visible (T1c), all of them had a Gleason score under 7 and half of them could be considered clinically relevant. CONCLUSIONS: Lowering PSA cutoff point from 4 to 3 ng/ml improved the detection rate in 21.4% not jeopardizing the biopsy performance. Therefore we think that the group of patients with PSA between 3 and 3.9 ng/ml as candidates for prostate biopsy, should be included in screening programs.

[Selective bladder sparing with transrectal resection of muscle-infiltrating tumors]. / Preservación vesical selectiva mediante resección transuretral de los tumores músculo-infiltrantes.

OBJECTIVE: To disclose te ability of TUR as monotherapy in muscle invasive bladder cancer. MATERIAL AND METHODS: 27 patients with muscle-invasive bladder cancer recruited throughout 1991-1999 were allocated into a protocol based on TUR. 30-45 days after the first TUR a second procedure was performed. The number of recurrences and progressions was registered. Progression-free survival and survival were analyzed using Kaplan-Meier estimates. RESULTS: Two patients were excluded due to persistence of muscle-invasive disease after the second resection. 8 subjects (32%) were lost in follow-up. 17 were eventually evaluable. 12 patients (70.5%) had recurrences. Eventually, 4 more cystectomies were undertaken for invasive recurrences (4/17, 23.5%). During the study period, 3 deaths were recorder (3/17, 17.6%). The actuarial probability of progression at 93 months was estimated on 60%. CONCLUSIONS: 75% of patients retained their bladders. The proportion of patients lost in follow-up was very high. Patients must commit to a close surveillance.

[Preliminary results of the treatment of high grade (T1G3) superficial tumors of the bladder with transurethral resection]. / Resultados preliminares del tratamiento de los tumores vesicales superficiales de alto grado (T1G3) mediante resección transuretral.

OBJECTIVE: To examine the results of monotherapy with TUR in the treatment of primary T1G3 transitional cell carcinoma (TCC). METHODOLOGY: Thirty-two patients with primary TCC of the bladder were allocated into a surveillance program. Risk factors for progression to muscle-invasive disease were determined. Immediately, projections of disease-free and progression-free survival were calculated. RESULTS: Five patients (15.6%) were lost in follow-up. Twenty-three (85%) had superficial recurrences. Four patients (14.8%) progressed to muscle-invasive or metastatic disease. No independent risk-factors for progression were disclosed. Median disease-free survival was 8 months. Projection of the risk of recurrence at 79 months was 84.9%. Median time to progression has not been reached yet. Projection of progression at 79 months was 46.3%. CONCLUSIONS: The above mentioned treatment schedule is associated with very high recurrence rates. In addition, recurrences are very frequent. Nevertheless, in the medium run, projections of progression suggest that surveillance can be an alternative to other treatments in the management of T1G3 TCC of the bladder.

[Role of PSA velocity in the detection of prostate cancer. A study of 986 males]. / Papel de la velocidad del PSA en la detección del cáncer de próstata. Un estudio con 986 varones.

OBJECTIVE: To analyze the role of PSA velocity (PSAV) in the detection of prostate cancer (Pca) when compared to other valid alternatives. PATIENTS AND METHODS: From a Pca screening program, 986 men were evaluated in two visits (601 of them agreed for a third visit). Serum PSA was performed in every visit (PSA1, PSA2 and PSA3). All Pca diagnosed after PSA1 were excluded. Criteria for biopsy (PSA2 and PSA3) were PSA > 4 ng/ml, or PSAV > 0.7 ng/ml/year. Diagnostic performance of PSAV was compared with other options (PSA alone, DRE, and PSA density -PSAD-). RESULTS: Median age was 57 years. Median interval between visits were 679 days and 852.5 days respectively. During PSA2, 122 biopsies were indicated (91 performed). After PSA3, 78 were indicated and 24 done. This great proportion of not biopsied men was due to refusal. Seven Pca were detected during PSA2, and 5 during PSA3. Sensitivity of PSAV (two draws) was 0.86, specificity 0.95, missed 1 cancer of 7 and needed 7.5 biopsies per cancer. When three PSA samples available, PSAV missed 2 cancers of 5, and 2.7 biopsies per cancer needed. PSA alone detected 86% of the cancers, multiplying by 2 the number of biopsies needed. Not DRE, nor PSAD improved the diagnostic performance of PSAV when combined with this parameter. CONCLUSIONS: Diagnostic performance of PSAV was found to be unacceptable in our hands. The need for a third biopsy in these studies make them difficult to reproduce. Validation of PSAV is a difficult task to achieve, we think its role remains questioned.

[Nutcracker syndrome. Report of a case and review of the literature]. / Síndrome del cascanueces. A propósito de un caso y revisión de la literatura.

Nutcracker syndrome is caused by compression of left renal vein between the aorta and the superior mesenteric artery. This phenomenon results in left renal venous hypertension, left gonadal vein varices and unilateral hematuria. We report a typical case of nutcracker syndrome and we review the literature in an effort to explain this pathology.

[Clinical significance of prostatic intraepithelial neoplasia]. / Significado clínico de la neoplasia intraepitelial prostática.

OBJECTIVE: To determine the value of high grade prostatic intraepithelial neoplasia (with or without the influence of certain risk factors) in predicting prostate cancer in subsequent biopsies. METHODS: The study comprised 41 patients from a prostate cancer screening program with high grade prostatic intraepithelial neoplasia. Subsequent biopsies were reviewed and the probability of detecting prostate cancer was calculated. We analyzed the influence of age, DRE and transrectal US findings, PSA levels and PSA density on the results of the repeat biopsies. RESULTS: The patients were aged 50 to 83 years (mean 62.8 +/- 1.6 SD, median 61). Only 27 of the 41 patients with high grade prostatic intraepithelial neoplasia accepted a repeat biopsy. Of these, prostate cancer was demonstrated in 11 (40.7%; all cases were clinically localized at the time of diagnosis) and 16 showed no changes (59.3%) on repeat biopsy. By univariate and multivariate analysis, patient age, DRE and transrectal US findings, PSA levels and PSA density were not found to be predictors of cancer in the subsequent biopsies. CONCLUSIONS: The finding of high grade prostatic intraepithelial neoplasia in the prostate biopsy carries a high probability of detecting cancer in subsequent biopsies. We therefore advocate performing a repeat biopsy in these patients.

[Mid-term results of a program for the monitoring of superficial bladder tumors]. / Resultados a medio plazo de un programa de vigilancia en los tumores vesicales superficiales.

OBJECTIVE: To identify the medium-term clinical prognostic factors for recurrence and progression in superficial bladder tumors and to analyze the efficacy and safety of the surveillance program. METHODS: 135 patients with primary superficial bladder tumor (Ta: 57, T1: 76, Tx: 2, grade I: 51, grade II: 70, grade III: 12, unknown grade: 2) were evaluated by cystoscopy/cytology alternately with ultrasound/cytology during the first two years, and by ultrasound and cytology yearly after the third year. The influence of tumor characteristics (stage, grade, size and number) and patient age and sex on tumor recurrence and progression were analyzed. The disease-free interval was expressed through an actuarial curve. The relationships between the annual recurrence rate and disease-free interval, and tumor and patient characteristics were analyzed. The influence of each variable in the presence of the other covariables was determined by multivariative analysis using a logistic regression model. RESULTS: The recurrence rate was 51.3% and the progression rate was 2.75%. The mean recurrence rate was 0.59 and the mean disease-free interval was 16.2 months. Tumor grade, size and number significantly influenced recurrence. Tumor size and number influenced the annual recurrence rate. Similarly, tumor number and size were associated with a shorter disease-free interval. Logistic regression analysis showed a relationship between tumor number and recurrence (relative risk = 2.7), and identified tumor size as a characteristic of a high recurrence rate (relative risk = 3.3). None of the factors could predict a higher risk for tumor progression. CONCLUSIONS: The estimation of the risk factors shows a wide intra and interindividual variability. It might therefore be necessary to establish them for each institution. In the medium-term, surveillance can be considered effective in terms of the recurrence rate and safe in terms of the progression rate.