Síndrome de cascanueces: una causa infrecuente de hematuria / Nutcracker Syndrome: a Rare Cause of Hematuria

La hematuria en pediatría responde habitualmente a etiologías benignas. Una causa poco frecuente es el síndrome de cascanueces, que se define como la compresión de la vena renal izquierda entre la aorta y la arteria mesentérica superior, que deriva en una presión elevada en la vena renal izquierda con el desarrollo de venas colaterales y dilataciones varicosas. La prevalencia de este síndrome se desconoce. Cuando es sintomático ocasiona hematuria, proteinuria y dolor pélvico crónico. En la pubertad, el crecimiento rápido y el desarrollo de los cuerpos vertebrales pueden producir un estrechamiento del ángulo entre la aorta y la arteria mesentérica superior. Se describe el caso de una adolescente con diagnóstico de carcinoma mucoepitelial metastásico óseo múltiple que presenta hematuria anemizante. Se arribó al diagnóstico de síndrome de cascanueces y se discutieron las opciones de tratamiento. Finalmente, con el uso de realce del calzado para corrección de la escoliosis, se atenuó significativamente la hematuria. (AU)

In pediatrics, hematuria usually responds to benign etiologies. A rare cause is nutcracker syndrome, defined as compression of the left renal vein between the aorta and the superior mesenteric artery, resulting in elevated pressure in the left renal vein with the development of collateral veins and varicose dilatation. The prevalence of this syndrome is unknown. When symptomatic, it causes hematuria, proteinuria, and chronic pelvic pain. At puberty, the rapid growth and development of the vertebral bodies can produce a narrowing of the angle between the aorta and the superior mesenteric artery.We describe the case of a teenage girl diagnosed with multiple metastatic mucoepithelial carcinoma of bone who presented anemia-producing hematuria. The diagnosis of nutcracker syndrome was arrived at with consideration of the therapeutic options. Finally, with shoe enhancement for scoliosis correction, hematuria was significantly lessened. (AU)

Manejo exitoso de síndrome de vejiga hiperactiva refractaria con toxina botulínica A / Successful management of refractory overactive bladder syndrome with botulinum toxin A

Introducción: El síndrome de vejiga hiperactiva (VHA) afecta hasta al 43% de las mujeres. La terapia escalonada incluye cambios de hábitos, fármacos y neuromodulación. Hasta el 40% de las pacientes llegan a requerir terapia avanzada alternativa, como toxina botulínica (TB). Objetivo: Reportar los resultados del tratamiento con toxina botulínica en mujeres con VHA refractaria a tratamiento de primera y segunda línea, en un hospital público en Chile. Método: Estudio de cohorte retrospectivo desde una base de datos recolectada prospectivamente del Hospital Sótero del Río entre 2018 y 2022. Se incluyeron 33 pacientes con tratamiento farmacológico y neuromodulación previa, con una edad promedio de 57 años, sometidas a inyección cistoscópica de TB a detrusor, analizando datos demográficos, antecedentes y complicaciones. Se realizó seguimiento con frecuencia miccional, paños/día, escala de gravedad de Sandvik (ISI) y encuesta Patient Global Impression Improvement (PGI-I). Resultados: Los datos comparativos pre/post TB, respectivamente, fueron: frecuencia miccional diurna 11/6 y nocturna 5/1; paños/día 5/3; ISI 8/3. Veinte de 33 mujeres refirieron estar excelente o mucho mejor (PGI-I). Conclusiones: Es posible realizar manejo con TB en mujeres con VHA refractaria a primera y segunda línea, con buenos resultados e impacto significativo en la calidad de vida.

Introduction: Overactive bladder syndrome (OABS) affects up to 43% of women. Staggered therapy includes habit changes, drugs, and peripheral neuromodulation. Up to 40% of patients may require advanced alternative therapy such as botulinum toxin A (BT). Objective: To report the results of treatment with TB in women with OABS refractory to first- and second-line treatment in a public hospital in Chile. Method: Retrospective cohort study from prospectively collected database from Hospital Sótero del Río between 2018 and 2022. Thirty-three patients with previous pharmacological treatment and neuromodulation were included, with an average age of 57 years, undergoing cystoscopic injection of TB to detrusor. Demographic data, history, and complications were analyzed. Follow-up was performed with voiding frequency, cloths/day, Sandvik Severity Scale (ISI) and Patient Global Impression Improvement (PGI-I) survey. Results: Comparative data pre/post TB, respectively showed: daytime voiding frequency 11/6 and nighttime 5/1; cloths/day 5/3; ISI 8/3. 20 of 33 women reported being excellent or much better (PGI-I). Conclusions: TB management in women with OABS refractory to first- and second-line treatment has good results and significant impact on quality of life.

Persistencia de uraco en paciente joven. Reporte de caso / Persistence of urachus in a young patient. Case report

Introducción. Durante el desarrollo embrionario normal, se espera que el denominado uraco o ligamento umbilical mediano se oblitere a las 32 semanas de gestación. Ante una obliteración incompleta surgen las diferentes anomalías, siendo las más frecuentes el quiste y la fístula urinaria umbilical. El objetivo de este artículo fue presentar el caso de una paciente joven, sin comorbilidades, con quiste de uraco. Caso clínico. Mujer indígena de 19 años que consultó por dolor leve en hipogastrio, asociado a síntomas urinarios y distensión abdominal. Se sospechó en primera instancia cólico renal, pero ante hallazgos ecográficos de masa infraumbilical y reactantes de fase aguda elevados, la impresión diagnóstica cambió a sepsis secundaria a absceso intraabdominal. Posterior a tomografía y cistoscopía con calibración uretral se identificó pequeño divertículo en cúpula vesical, que sugirió el diagnóstico de uraco persistente, por lo que la paciente fue llevada a intervención quirúrgica para su resección, con evolución favorable. Discusión. El quiste de uraco es una anormalidad infrecuente, en su mayoría asintomática y generalmente de hallazgo incidental en la población anciana, por lo que se requiere de imágenes y manejo multidisciplinar para su correcto diagnóstico y abordaje. Conclusión. Son pocos los casos de uraco persistente reportados, y mucho menos en el sexo femenino. Dada la posibilidad de complicaciones tardías es importante el seguimiento para su manejo. Este caso se ha controlado de manera ambulatoria por 2 años

Introduction. During normal embryonic development, it is expected that the so-called urachus or median umbilical ligament will be obliterated at 32 weeks of gestation. In the face of incomplete obliteration, the different anomalies of the urachus arise. The most frequent anomaly of the urachus is the cyst followed by the umbilical urinary fistula. The objective of this article was to present the case of a young patient without comorbidities with urachal cyst. Clinical case. A 19-year-old indigenous woman consulted for mild hypogastric pain associated with urinary symptoms and abdominal distension. Renal colic was suspected at first, but due to ultrasound findings of an infraumbilical mass and high acute phase reactants, the diagnostic impression changed to sepsis secondary to an intra-abdominal abscess. After tomography and cystoscopy with urethral calibration, a small diverticulum was identified in the bladder dome, suggesting a diagnosis of persistent urachus, for which the patient was taken to surgery for its resection, with favorable evolution. Discussion. The urachal cyst is a rare abnormality, mostly asymptomatic and usually incidental finding in the elderly population. Imaging and multidisciplinary management are required for its correct diagnosis and approach. Conclusion. There are few reported cases of persistent urachus and much less in females. Given the possibility of late complications, follow-up is important for its management, in this case we have carried out control for 2 years

Lean: Introduction of a Quality Improvement Concept into Percutaneous Nephrolithotomy to Improve Efficiency while Maintaining Safety / Lean: introducción de un concepto en la nefrolitotomía percutánea para mejorar la eficiencia mientras se mantiene la seguridad

Introduction and objective Standardization of surgical interventions reduces complications and costs and positively impacts intra and postoperative outcomes. Implementation of the lean concept, initially proposed in the auto industry, now becomes an interesting approach in the surgical setting. We want to present the results of how percutaneous nephrolithotripsy (PCNL) in a high-level center can be positively impacted by implementing the lean concept. Methods We evaluated a total of 140 PCNL procedures. Group 1 included all cases operated prior to implementing the lean concept and group 2 was composed of those operated after implementing the lean concept. We looked for all seven sources of waste to identify and modify our practice to improve efficiency and safety. We then collected intraoperative times and compared the ones prior to those after the implementation. Results After implementing the lean concept, with an average of six PCNL cases per day, a comparison was made to an equivalent number of cases prior to the lean implementation (group 1). The average total operative time for PCNL preintervention was 138 (confidence interval [CI]: 79 to 170) minutes and postlean intervention was 71.1 (CI: 43 to 157) minutes. Surgical time (cystoscopy to skin closure) was 36.1 (CI: 25 to 50) minutes prelean and 50 minutes postlean (CI: 23 to 154). For this last one, bilateral procedures were performed. Operative room turnover time was 27.8 (CI: 21 to 38) minutes prelean and 5.67 (CI: 3.5 to 12) minutes postlean. Induction time was 16.5 (CI: 5 to 55) minutes prelean and 5.4 (CI: 3.5 to 7.5) minutes postlean. Conclusion Implementation of the lean concept enables optimization of the surgical procedure, allowing hospitals to reduce costs and standardization.

Introducción y objetivo La estandarización de los procedimientos quirúrgicos reduce complicaciones, costos, y mejora resultados intra y postoperatorios. El concepto lean fue utilizado por primera vez en la industria automotriz. El presente trabajo busca implementar el concepto lean para optimizar el procedimiento de nefrolitotomía percutánea (NLP) en nuestro medio. Métodos Se realizaron 140 procedimientos de nefrolitotomía percutánea, los cuales se dividieron en 2 grupos: uno en el cual se registraron los tiempos intraoperatorios, y el segundo en que se registraron los tiempos luego de la implementación del concepto lean. Resultados Durante el período estudiado, se realizaron 70 procedimientos luego de la implementación del concepto lean, y se logró realizar un promedio de 6 procedimientos por día. Se compararon los tiempos operatorios, y se encontró un tiempo operatorio total promedio de 138 (intervalo de confianza [IC]: 79 a 170) minutos pre-lean, y de 71,1 (IC: 43 a 157) minutos post-lean. El tiempo quirúrgico (cistoscopia a cierre de piel) pre-lean fue de 36,1 (IC: 25 a 50) minutos, y el post-lean fue de 50 (IC: 23 a 154) minutos. Para este último, se trató de procedimientos bilaterales. El cambio de sala fue de 27,8 (IC: 21a 38) minutos pre-lean, y de 5,67 (IC: 3.5 a 12) minutos post-lean. El tiempo de inducción fue de 16.5 (IC: 5 a 55) minutos pre-lean, y de 5.4 (IC: 3.5 a 7.5) minutos post-lean. Conclusiones La implementación del concepto lean permite optimizar el procedimiento, con reducción de costos y estandarización del modelo de atención para cualquier centro asistencial. La movilización de los especialistas en nuestro modelo de atención permite un mayor cubrimiento poblacional de alta calidad.

Absceso recurrente de la glándula de Skene en paciente joven: reporte de caso / Recurrent abscess of Skene's gland in a young patient: case report

Las glándulas de Skene se encuentran localizadas en la región lateral de la uretra distal, por lo general son asintomáticas sin embargo en ciertas ocasiones pueden obstruirse creando acumulación de líquido en su interior, el cual provoca síntomas, abscesos o quistes que pueden ser tratados con tratamiento médico o quirúrgico. En este caso se presenta una mujer que consulta en múltiples ocasiones por salida de secreción purulenta de la glándula de skene, ya tratada con esquemas antibióticos en 3 ocasiones, sin embargo al persistir con recurrencia de absceso a pesar de antibioterapia se realiza abordaje quirúrgico para resección de la misma (AU)

Skene's glands are located in the lateral region of the distal urethra, are usually asymptomatic however on certain occasions they can become clogged creating accumulation of fluid inside, which causes symptoms, abscesses or cysts They can be treated with medical or surgical treatment. In this case, a woman is presented who consults in multiple sometimes due to discharge of purulent secretion from the skene's gland, she already treated with antibiotic regimens on 3 occasions, however When abscess recurrence persists despite antibiotic therapy, performs surgical approach for its resection

Proteomic research and diagnosis in bladder cancer: state of the art review

ABSTRACT Purpose: Proteomic biomarkers have been emerging as alternative methods to the gold standard procedures of cystoscopy and urine cytology in the diagnosis and surveillance of bladder cancer (BC). This review aims to update the state of the art of proteomics research and diagnosis in BC. Materials and Methods: We reviewed the current literature related to BC research on urinary, tissue, blood and cell line proteomics, using the Pubmed database. Findings: Two urinary protein biomarkers are FDA-approved (NMP22® and BTA® tests), only if performed along with cystoscopy for surveillance after initial diagnosis, but not in the primary diagnostic setting due to high false-positive rates in case of infections, stones and hematuria. There are a great number of non-FDA approved proteins being studied, with good preliminary results; panels of proteins seem valuable tools to be refined in ongoing trials. Blood proteins are a bigger challenge, because of the complexity of the serum protein profile and the scarcity of blood proteomic studies in BC. Previous studies with the BC tissue proteome do not correlate well with the urinary proteome, likely due to the tumor heterogeneity. Cell line proteomic research helps in the understanding of basic mechanisms that drive BC development and progression; the main difficulty is culturing low-grade tumors in vitro, which represents the majority of BC tumors in clinical practice. Conclusion: Protein biomarkers have promising value in the diagnosis, surveillance and prognostic of BC. Urine is the most appropriate body fluid for biomarker research in BC due to its easiness of sampling, stability and enrichment of shed and secreted tumor-specific proteins. Panels of biomarkers may exhibit higher sensitivity than single proteins in the diagnosis of BC at larger populations due to clinical and tumor heterogeneity. Prospective clinical trials are warranted to validate the relevance of proteomic data in the clinical management of BC.

Analysis of self-control trial results of narrow band imaging and white light in transurethral resection of bladder tumor / 北京大学学报(医学版)

OBJECTIVE@#To investigate the effect of NBI assisted white light transurethral resection of bladder tumor (TURBT) in the treatment of bladder urothelial carcinoma and to summarize the experience of narrow band imaging (NBI) operation.@*METHODS@#Patients with bladder urothelial carcinoma were selected, and TURBT was performed after anesthesia. First of all, the bladder tumor was found and resected under white light. Then we replaced with NBI, looked for suspicious lesions and resected them, The specimens excised under white light and NBI were collected separately. The number, location and pathological results of the lesions under white light were recorded, and the residual lesions under NBI were also recorded. To evaluate the effect of NBI, the ratio of residual bladder tumor was calculated. The cases were divided into three groups according to the time sequence. The clinical data of each group were collected and the learning curve of TURBT under NBI assisted white light was observed.@*RESULTS@#A prospective study of 45 patients with bladder tumor from April 2018 to January 2020, including 32 males and 13 females, aged from 23 to 89 years, with an average age of 65.2 years. All the operations were successfully completed, without obvious complications after operation. Nine cases were single and 36 cases were multiple. The maximum diameter of the tumors was 0.5 to 4.0 cm, with an average of 2.2 cm. The histopathology of the resected tissue under white light was urothelial carcinoma, and 19 cases (42.2%) were pathologically positive by NBI resection. The 45 cases were divided into three groups according to the time sequence, 15 cases in each group. The true positive rate of NBI was 33.3%, 46.7% and 46.7%, respectively, and the false positive rate was 60.0%, 46.7% and 26.7%, respectively in the three groups.@*CONCLUSION@#TURBT is an effective way to treat bladder urothelial cancer, NBI is an effective supplement of white light, which can increase the detection rate of bladder cancer and reduce post-operative recurrence. The NBI light source has a certain learning curve. With the increase of cases, the false-positive rate of NBI is gradually reduced. After the NBI operator has rich experience, the recognition degree of flat tumor is gradually improved under white light, and the residual rate of NBI is reduced after the removal under white light.

Intervenciones no farmacológicas para la disminución del dolor en cistoscopia / Non-Pharmacological Interventions to Reduce Pain in Cystoscopy

Objetivo Generar una aproximación a las terapias no farmacológicas que disminuyan el dolor durante la realización de la cistoscopia. Métodos Se realizó una búsqueda de la literatura para identificar artículos relevantes con respecto al tópico, utilizando como palabras clave: cistoscopia, dolor, terapia no farmacológica en cistoscopia y terapias alternativas. La búsqueda se hizo a través de Medline y Embase. Se realizó una revisión narrativa. Resultados Aunque la cistoscopia flexible aumenta la tolerancia, especialmente en pacientes masculinos, el dolor sigue siendo inevitable durante la misma. Se han estudiado diferentes intervenciones no farmacológicas orientadas a disminuir el dolor y la ansiedad durante la cistoscopia, entre las que se encuentran: escuchar música, tomar la mano del paciente, ver el procedimiento en tiempo real, el aumento de la presión hidrostática, insuflación con aire y la hipnosis. Conclusión Esas intervenciones podrían ser usadas como adyuvantes en la disminución del dolor y la ansiedad durante la cistoscopia, principalmente la masculina. Sin embargo, se requieren más estudios que comprueben su uso clínico apropiado.

Objective To generate an approach to non-pharmacological therapies that reduce pain during cystoscopy. Methods We searched the literature to identify relevant articles regarding the topic, using as keywords: cystoscopy, pain, non-pharmacological therapy in cystoscopy and alternative therapies. The search was made through Medline and Embase. A narrative review was made. Results Although flexible cystoscopy increases tolerance, especially in male patients, pain remains unavoidable during it. Different non-pharmacological interventions aimed at reducing pain and anxiety during cystoscopy have been studied, among which are: listening to music, taking the patient's hand, seeing the procedure in real time, increasing hydrostatic pressure, insufflation with air and hypnosis. Conclusion These interventions could be used as adjuvants in the reduction of pain and anxiety during cystoscopy, mainly male. However, more studies are required to prove their appropriate clinical use.

Genitourinary involvement in colorectal cancer: pre-operative diagnostic utility of CEA, computed tomography and cystoscopy in predicting surgical involvement

OBJECTIVE@#This study aims to describe the demographics, clinical characteristics of patients, and the sensitivity and specifity of the clinical, laboratory, radiologic, diagnostic parameters in detecting histopathologically-proven urinary tract involvement in primary colorectal cancer patients referred to the urology service in the Philippine General Hospital. @*METHODS@#This was a retrospective, cross-sectional study. The study included patients referred to the Division of Urology from the Division of Colon, Rectal and Anal Surgery January 1, 2018 to December 31, 2018. All patients diagnosed with colorectal malignancy and referred to the Urology service were included in the study, including their cystoscopy, axial tomography, CEA and symptom assessment scores.@*RESULTS@#Fifty-eight patients were included in the study and, 43% were rectal cancers and 33% were sigmoid cancers. Sensitivities and specificities were as follows. Symptoms 40%, 84%, Cystoscopy, 45%, 100%; Axial tomography 75%, 79%. Surgical involvement correlated with histopathologic involvement with a specificity of 52%. CEA did not discriminate between cohorts of positive or negative involvement.@*CONCLUSION@#Cystoscopy, axial tomography and symptom assessment had high positive predictive values. All diagnostics had low negative predictive values when taken in isolation. Surgical assessment correlated with histopathologic findings in half of the population. CEA did not discriminate between those with surgical involvement and those without. A multi-modality assessment strengthens detection of surgical involvement preoperatively.

Acute postoperative sepsis mimicking symptomology suspicious for malignant hyperthermia: case report / Sepse aguda pós-operatória simulando sintomatologia suspeita para hipertermia maligna: relato de caso

Abstract Background: Sepsis is a life-threatening organ dysfunction with non-specific clinical features that can mimic other clinical conditions with hyper metabolic state such as malignant hyperthermia. Perioperatively anesthesia providers come across such scenarios, which are extremely challenging with the need for urgent intervention. Objective: To illustrate the need for early intervention and consultation for added assistance to approach and rule out malignant hyperthermia and other possible causes during such a scenario. Case report: A 63-year-old male underwent an uneventful elective flexible cystoscopy and transrectal ultrasound-guided prostate biopsy. Postoperatively he developed symptoms raising suspicion for malignant hyperthermia. Immediately malignant hyperthermia protocol was initiated that included administration of dantrolene and consultation of malignant hyperthermia association hotline along with other diagnostic and interventional management aimed at patient optimization. While early administration of dantrolene helped in hemodynamically stabilizing the patient, the consultation with other providers and malignant hyperthermia association hotline along with repeated examinations and lab works helped in ruling out malignant hyperthermia as the possible diagnosis. The patient later recovered in the intensive care unit where he was treated for the bacteremia that grew in his blood cultures. Conclusions: Sepsis shares clinical symptoms that mimic malignant hyperthermia. While sepsis rapidly progresses to secondary injuries, malignant hyperthermia is life threatening. Providing ideal care requires good clinical judgment and a high level of suspicion where timely and appropriate care such as early administration of dantrolene and consultation of malignant hyperthermia association hotline for added assistance can influence positive outcomes.

Resumo Justificativa: A sepse é uma disfunção orgânica fatal com características clínicas inespecíficas que podem imitar outras condições clínicas com quadro hipermetabólico, como a hipertermia maligna. Os cenários são extremamente desafiadores para a anestesia perioperatória e requerem intervenção urgente. Objetivo: Ilustrar a necessidade de intervenção e consulta precoces para uma assistência adicional na abordagem e exclusão de hipertermia maligna e outras possíveis causas durante tal cenário. Relato de caso: Paciente do sexo masculino, 63 anos, submetido à cistoscopia eletiva com cistoscópio flexível e biópsia transretal da próstata guiada por ultrassom sem intercorrências. No pós-operatório, o paciente desenvolveu sintomas que levantaram a suspeita de hipertermia maligna. O protocolo de hipertermia maligna foi imediatamente iniciado, inclusive a administração de dantrolene e uma consulta pela linha direta da associação de hipertermia maligna, juntamente com outros diagnósticos e manejos intervencionistas com vistas ao aprimoramento do paciente. Enquanto a administração precoce de dantrolene ajudou na estabilização hemodinâmica do paciente, a consulta com outros anestesistas e com a Associação de Hipertermia Maligna, juntamente com repetidos exames físicos e laboratoriais, ajudou a excluir a hipertermia maligna como o possível diagnóstico. O paciente recuperou-se mais tarde na unidade de terapia intensiva, onde recebeu tratamento para a bacteremia detectada em suas hemoculturas. Conclusões: A sepse compartilha sintomas clínicos que mimetizam a hipertermia maligna. Enquanto a sepse progride rapidamente para lesões secundárias, a hipertermia maligna é uma ameaça à vida. Proporcionar o tratamento ideal requer um bom julgamento clínico e um alto nível de suspeita quanto aos cuidados oportunos e apropriados, como a administração precoce de dantrolene e a consulta pela linha direta da Associação de Hipertermia Maligna para assistência adicional, que podem resultar em desfechos positivos.

Non-functional paraganglioma of urinary bladder managed by transurethral resection

ABSTRACT Purpose As a rare bladder tumor, paraganglioma of the urinary bladder (PUB) is frequently misdiagnosed as bladder cancer, particularly for the non-functional type. To date, transurethral resection remains a controversial treatment for non-functional PUB. This study aimed to identify the clinical features, pathological characteristics, prognosis, and safe/effective treatment of non-functional PUB using transurethral resection of the bladder tumor (TURBT). Materials and Methods The clinical records, radiological data, pathological characteristics and follow-up times were retrospectively reviewed in 10 patients with clinically and pathologically proven non-functional PUB in our hospital from January 2008 to November 2016. All patients underwent TURBT treatment. Results The incidence of non-functional PUB in patients with bladder cancer was 0.17%. The mean age at diagnosis was 44.5 ± 13.6 years (range, 29-70 years), and the patient population had a female: male ratio of 3: 2. No patients had excess catecholamine (CA) whilst four patients had painless hematuria. All neoplasms were completely resected via TURBT. The majority of samples were positive for immunohistochemical markers including chromogranin A (CgA) and Synaptophysin (Syn), but were negative for cytokeratins (CKs). Only a single recurrence was observed from the mean follow-up period of 36.4 ± 24.8 months. Conclusion Complete TURBT is a safe and efficient treatment that serves both diagnostic and therapeutic purposes. Histopathological and immunohistochemistry examinations are mandatory for diagnostic confirmation. Long-term follow-up is recommended for patients with non-functional PUB.

Removal of intramural trapped intrauterine device by cystoscopic incision of bladder wall

ABSTRACT A healthy 37 - year - old woman referred to our clinic with one - year history of recurrent urinary tract infection, dysuria and frequency. Her past medical history informed us that an IUD (Copper TCu380A) had been inserted 11 years ago. Eleven months after the IUD insertion she had become pregnant, unexpectedly. At that time, she had undergone gynecological examination and abdominal ultrasound study. However, the IUD had not been found, and the gynecologist had made the diagnosis of spontaneous fall out of the IUD. She had experienced normal pregnancy and caesarian section with no complications. On physical examination, pelvic examination was normal and no other abnormalities were noted. Urinalysis revealed microhematuria and pyuria. Urine culture was positive for Escherichia coli. Ultrasound study revealed a calculus of about 10 mm in the bladder with a hyperdense lesion. A plain abdominal radiograph was requested which showed a metallic foreign body in the pelvis. We failed to remove the IUD by cystoscopic forceps because it had strongly invaded into the uterine and bladder wall. Despite previous papers suggesting open or laparoscopic surgeries in this situation (1, 2), we performed a modified cystoscopic extraction technique. We made a superficial cut in the bladder mucosa and muscle with J - hook monopolar electrocautery and extracted it completely with gentle traction. This technique can decrease the indication of open or laparoscopic surgery for extraction of intravesical IUDs. In the other side of the coin, this technique may increase the risk of uterovesical fistula. Therefore, the depth of incision is important and the surgeon should cut the bladder wall superficially with caution. Although present study is a case report which is normally classified as with low level of evidence, it seems that our modified cystoscopic extraction technique is a safe and useful method for extraction of partially intravesical IUDs.

Leiomioma vesical de crecimiento extramural: Una presentación infrecuente / Extramural Growth Bladder Leiomyoma: An Infrequent Presentation

Introducción Los leiomiomas son tumores benignos de músculo liso y pueden encontrarse en cualquier parte del tracto urinario, la mayoría se origina en la vejiga. Se presentan más en mujeres y deben ser considerados como diagnóstico diferencial en cualquier tumor de vejiga. El objetivo de este trabajo es reportar el caso de una paciente con un hallazgo incidental de leiomioma de vejiga y de localización infrecuente; además de considerarse una patología poco frecuente. Reporte de caso Paciente femenina de 40 años, ingresa por urgencias con cuadro de dolor abdominal en fosa iliaca derecha, valorada por cirugía general que realiza una presunción diagnóstica de apendicitis aguda y solicita estudios complementarios que evidencian proceso inflamatorio apendicular vs mucocele apendicular en la tomografía axial computarizada (TAC), por lo que se decide realizar apendicectomía por laparoscopia. Durante el procedimiento se evidencia lesión nacarada irregular dependiente de la cúpula vesical, por lo que se procede a interconsultar durante el procedimiento con el servicio de urología. El urólogo realiza cistoscopia sin evidencia de lesiones endoluminales. Se realiza excisión de la lesión junto con apendicectomía, sin complicaciones. La patología reporta leiomioma de vejiga. Discusión y Conclusiones Los leiomiomas de vejiga son tumores benignos poco frecuentes. Por tratarse de una patología que infrecuentemente presenta síntomas, puede hallarse incidentalmente y debe ser tenida en cuenta como diagnóstico diferencial en presencia de masas vesicales. Las imágenes son de gran ayuda diagnostica, sin embargo, será la histopatología quien aporte el diagnóstico definitivo. El tratamiento podrá variar de acuerdo al tamaño y localización del tumor.

Introduction Leiomyomas are benign smooth muscle tumor that can be found in any place of the urinary tract, most of them originated from the bladder. They are presented most frequently in women and must be considered as a differential diagnosis with any bladder tumor. The objective of this study is to present a case of a patient with an incidental finding of a bladder leiomyoma and infrequent location; besides being a rare disease. Case Presentation Female patient of 40 years-old, attends the emergency room for abdominal pain in lower right quadrant. Is valorated by the surgery team, that suspected acute appendicitis and made complementary studies. The axial computerized tomography shows an inflammatory process in the cecal appendix vs appendicular mucocele. The patient was undertaken to appendectomy by laparoscopy. During the procedure, a nacreous irregular lesion dependent on the bladder dome was detected, the urology service was consulted intraoperatory call to the urology service was made. A cystoscopy was made, with no endoluminal lesions identified. An excision of the lesion and appendectomy were made without complications. Pathology of the lesion reported a bladder leiomyoma. Discussion and Conclusion Bladder leiomyomas are very uncommon benign tumors. Most cases are asymptomatic, they are an incidental finding and should always be considered a differential diagnosis of any vesical mass. Images should be helpful diagnostic tool but the gold standard is the histopathological study. The treatment might change according to the size and location of the tumor.

Reconstrucción de pene luego de necrosis de glande por priapismo / Penile Reconstruction after Glans Necrosis by Priapism

Introducción El priapismo se define como una erección parcial o completa que dura más de 4 horas en ausencia de estímulo sexual. Se clasifica en isquémico, no isquémico e intermitente. El primero corresponde a la mayoría de casos y puede producirse por un estímulo sexual o por medicamentos. El manejo inicial consiste en la aspiración de los cuerpos cavernosos y la inyección de simpaticomiméticos. Cuando esas medidas fallan, el manejo quirúrgico está indicado. Entre las complicaciones más frecuentes está la disfunción eréctil, sin embargo, en la literatura, hay muy pocos reportes de necrosis de pene. Descripción del Caso Clínico Paciente de 60 años de edad que presentó priapismo isquémico luego de la inyección intracavernosa de prostaglandina E. Viene a consulta y le realizan lavado de cuerpos cavernosos con inyección de simpaticomiméticos que no fue exitoso; por lo que le realizan fístula espongio-cavernosa distal (Al-Ghorab) y rafia de uretra por lesión advertida. Consulta nuevamente por persistencia de edema, áreas necróticas y sangrado en glande. Se decidió iniciar manejo médico. Presentó evolución estacionaria y aumento en necrosis por lo que se derivó con cistostomía y se realizó desbridamiento de tejido necrótico inicialmente. Posteriormente se realizó Reconstrucción peneana + Uretroplastia peneana + Lavado desbridamiento de tejidos + Cistoscopia con buena evolución clínica. Conclusiones Existen diferentes factores de riesgo para presentar priapismo de origen isquémico como es la inyección de medicamentos intracavernosos. La principal complicación que se presenta es la disfunción eréctil. Sin embargo, hay pocos casos descritos de necrosis de glande. En el caso de nuestro paciente se plantean diferentes hipótesis como factores contribuyentes a la necrosis como son el uso de simpaticomiméticos y/o la desvascularización del glande posterior a la cirugía. Al enfocar ese tipo de paciente, es indispensable realizar un adecuado manejo inicial para prevenir ese tipo de complicación que, aunque es poco frecuente, puede resultar catastrófica.

Introduction Priapism is defined as a prolonged and persistent penile erection that is unrelated to sexual stimulation and lasts longer than 4 hours in duration. It is classified as ischemic (low flow), non-ischemic (high flow), and stuttering (recurrent). Ischemic priapism is the most frequent. Initial treatment consists of corpora cavernosa aspiration. When it fails, surgical treatment is indicated. Erectile dysfunction is a frequent complication, however glans necrosis has been reported too. Case Report A 60 year-old patient with ischemic priapism after prostaglandin E intracavernous injection consulted. Initial treatment was corpora cavernosa aspiration without detumecense and then a distal espongio-cavernous fistula was done. Some days later, he presented edema, bloods and necrotic areas in his glands. Conservative medical treatment was done without success and a surgical treatment was considered. Reconstructive procedure was done with good evolution. Conclusions Ischemic priapism could be presented after intracavernous injection with low frequency. However, an appropriate treatment has to be done to prevent complications as penile necrosis. In this patient, there are some risk factors that could be contribute to glans necrosis as simpatico-mimetics used, lost of vascularization with surgery. When focusing on this type of patient, it is essential to carry out an adequate initial management to prevent this type of complication that, although rare, can result catastrophic

Evaluación de la eficacia de fosfomicina trometamol y gentamicina en la profilaxis de la cistoscopia flexible tras el estudio de los patógenos de nuestro entorno / Evaluation of the Efficacy of Fosfomycin Trometamol and Gentamicin in the Prophylaxis of Flexible Cystoscopy after the Study of Microflora in our Environment

Objetivo Optimizar el uso de antibióticos en la profilaxis de la cistoscopia flexible estudiando los patógenos más frecuentes de nuestro entorno y eligiendo el antibiótico según sus antibiogramas. Métodos Desde Enero del 2015 hasta Noviembre del 2015, se analizaron los urinocultivos de nuestra área, se eligió el antibiótico en función a su sensibilidad frente a los patógenos más frecuentes y se comparó con un antibiótico de amplio espectro. Desde Enero del 2016 hasta Diciembre del 2016, se realizaron las cistoscopias agrupando a los pacientes en: Grupo 1: Pacientes sin profilaxis; Grupo 2: Profilaxis con Gentamicina 240 mg; Grupo 3: Profilaxis con antibiótico seleccionado. Como variables principales se definieron la presencia de bacteriuria asintomática e ITU tras la realización de la cistoscopia flexible. Resultados Se analizaron 8.530 urinocultivos y se eligió la Fosfomicina Trometamol 3 gr como profilaxis. Se realizaron 244 cistoscopias distribuidas: Grupo 1: 86 (35%); Grupo 2: 72 (30%); Grupo 3: 86 (35%). Se detectó bacteriuria asintomática postcistoscopia en 6 pacientes (2,5%) en el Grupo 1, 7 pacientes (2,9%) en el grupo 2 y 5 pacientes (2%) en el grupo 3 no presentando diferencias significativas (p 0.120). Desarrollaron ITUs postcistoscopia 1 paciente (0,4%) en el Grupo 1, 5 pacientes (2%) en el Grupo 2 y 2 pacientes (0,8%) en el Grupo 3 sin diferencias significativas (p 0.105). Conclusión La Fosfomicina es tan efectiva como la Gentamicina en la profilaxis de la cistoscopia. Para un uso correcto de los antibióticos, se recomienda el estudio de los patógenos de nuestro entorno.

Objective To optimize the use of antibiotics in the prophylaxis of flexible cystoscopy by studying the most frequent pathogens in our environment and choosing the antibiotic according to its antibiograms. Method Between January 2015 and November 2015, urine cultures were analyzed in our area, the antibiotic was chosen based on its sensitivity to the most frequent pathogens and compared with a broad spectrum antibiotic. From January 2016 to December 2016, cystoscopy was performed by grouping patients into: Group 1 - Patients without prophylaxis, Group 2 - Prophylaxis with 240 mg gentamicin, Group 3 - Selected antibiotic prophylaxis. The main variables were the presence of asymptomatic bacteriuria and UTI after flexible cystoscopy. Results 8530 urine cultures were analyzed and 3 g of fosfomycin trometamol was chosen as the prophylactic. There were 244 cystoscopies: Group 1: 86 (35%); Group 2: 72 (30%); Group 3: 86 (35%). Asymptomatic bacteriuria was detected in 6 patients (2.5%) in Group 1, 7 patients (2.9%) in Group 2 and 5 patients (2%) in Group 3, showing no significant differences (p = 0.120). Post-cystoscopic urinary tract infection developed in 1 patient (0.4%) in Group 1, 5 patients (2%) in Group 2 and 2 patients (0.8%) in Group 3, which showed no significant differences (p 0.105). Conclusion Fosfomycin is as effective as Gentamicin as a prophylactic in cystoscopy. The study of the pathogens in each environment is recommended to correctly prescribe the antibiotic.

Plasmacytoid Urothelial Carcinoma of the Bladder: Case Report and Review of the Literature / Carcinoma urotelial de vejiga, variante plasmocitoide: Reporte de un caso y revisión de la literatura

Introduction Plasmacytoid urothelial carcinoma (PUC) of the bladder is a rare histological variant, accounting for 1 to 3% of the invasive urothelial carcinomas, and it is typically aggressive. So far, it has not been well characterized, and the literature is based on reports and case series. Case Report A 70-year-old male patient presenting with 4 months of constitutional and urinary symptoms, with an ultrasound finding of bilateral hydronephrosis and diffuse thickening of the bladder walls. In the cystoscopy, trigone of infiltrated appearance, a biopsy wass performed, whose immunohistochemistry revealed a PUC. The abdominopelvic image showed an infiltrative lesion that compromised the muscle of the bladder and extended to the perivesical fat, without adequate plane of cleavage with the prostate and a single hypogastric adenopathy suspected of malignancy. It was classified as cT3b vs cT4aN1M0 (chest computed tomography [CT] negative for malignancy), and the patient was submitted to a radical cystoprostatectomy, extended pelvic lymphadenectomy and non-continent urinary diversion with ileal conduit. The pathology revealed a diffuse PUC with prostatic stromal involvement and 22 of 39 lymph nodes positive for malignancy. Finally, the patient presented a series of postoperative complications and died. Conclusion Plasmacytoid urothelial carcinoma of the bladder is a rare entity, characterized by high aggressiveness, an advanced stage at the time of diagnosis, and a poor prognosis. Currently, an aggressive approach is recommended due to its high invasive potential.

Introducción El carcinoma urotelial plasmocitoide (CUP) de la vejiga es una variante histológica poco frecuente; representa el 1 al 3% de los carcinomas uroteliales invasivos y es típicamente agresiva. Hasta el momento no ha sido bien caracterizada, y la literatura se basa en reportes y series de casos. Reporte de Caso Paciente masculino de 70 años presentando por 4 meses síntomas constitucionales y urinarios, con hallazgo ecográfico de hidronefrosis bilateral y engrosamiento difuso de las paredes vesicales. En la cistoscopia, trígono de apariencia infiltrada, se realizó biopsia cuya inmunohistoquímica reveló un CUP. En imagen abdominopélvica, se evidenció lesión infiltrativa que comprometía la muscular de la vejiga y se extendía a la grasa perivesical, sin adecuado plano de clivaje con la próstata y un único ganglio hipogástrico sospechoso de malignidad. Se clasificó como cT3b vs cT4aN1M0 (TAC tórax negativo para malignidad) y fue llevado a cistoprostatectomía radical, linfadenectomía pélvica extendida y derivación urinaria no continente con conducto ileal. La patología reveló un carcinoma urotelial variante difusa plasmocitoide con compromiso de estroma prostático y 22 de 39 ganglios positivos para malignidad. Finalmente, el paciente presentó una serie de complicaciones posoperatorias y falleció. Conclusión El carcinoma urotelial de vejiga variante plasmocitoide es una entidad poco frecuente, caracterizada por alta agresividad, un estadio avanzado al momento del diagnóstico, y un pobre pronóstico. En la actualidad, se recomienda un enfoque agresivo dado su alto potencial invasivo.

Clinical Features and Diagnosis of Encrusted Bladder Cancer / 中国医学科学院学报

Bladder cancer is a urological malignant tumor with high morbidity and mortality. Masses protruding into the bladder cavity is an important feature for clinical diagnosis of bladder cancer. However,patients with encrusted bladder cancer(EBC)do not present with masses protruding into the bladder cavity and thus this malignancy is often misdiagnosed. Four patients were admitted in Peking University People's Hospital from July 2015 to February 2017. All of them were males aged 40 to 77 years(mean:58 years). Patients were mainly manifested as frequent urination,urgency,nocturia,and decreased bladder capacity,with or without difficulty of voiding.Although the bladder walls were markedly thickened,there was no obvious mass on imaging scans. Three patients received urodynamic test,which showed the maximum capacity of the bladder was 41 to 128 ml(mean:91 ml). One patient presented with gross hematuria,two patients presented with microscopic hematuria,and the remaining one patient had no hematuria. No mass was observed by cystoscopy. All of the patients were diagnosed with bladder cancer by repeated biopsy or intraoperative frozen section analysis.