Control de la hemostasia durante la nefrectomía parcial laparoscópica sin renorrafia parenquimatosa: la experiencia Vivostat ® / Haemostasis Control during Laparoscopic Partial Nephrectomy without Parenchymal Renorrhaphy: the VIVOSTAT® Experience

Objetivo: Presentar nuestra experiencia en el control hemostático de la nefrectomía parcial laparoscópica utilizando un compuesto de fibrina autóloga (Vivostat system®), sin reconstrucción del parénquima renal. Material y métodos: Hemos realizado 45 nefrectomías parciales utilizando este agente hemostático. Los principales pasos quirúrgicos fueron: decolación, identificación del uréter, hilio y tumoración renal, control de la arteria renal con torniquete de Rummel, exéresis tumoral con bisturí armónico y aplicación del sellador de fibrina en el lecho quirúrgico en 2 fases (antes y después de la reperfusión renal). Se registraron datos de sangrado precoz o diferido. Resultados: Edad media: 63,9 años (33-80); tamaño medio del tumor 2,5cm (1,5-4); tiempo medio quirúrgico: 136,1minutos (90-180). Tiempo medio de isquemia caliente 19,2minutos (10-30). Pérdida sanguínea media: 97ml (50-300). Se realizaron puntos hemostáticos individuales antes de la aplicación del sellador de fibrina, en caso de sangrado activo importante (14 casos). No se registró ningún caso de sangrado ni fallo renal en el postoperatorio. Un paciente requirió transfusión sanguínea debido a gran hematoma en pared abdominal. El 65% fue carcinoma de célula clara renal, el 10% carcinoma papilar y un 20% fueron oncocitomas. La tasa de márgenes negativos fue del 100%. El tiempo medio de ingreso hospitalario fue 4 días (2-6). El seguimiento medio fue de 14 meses (5-45). Conclusiones: Excluir la renorrafia durante la nefrectomía parcial laparoscópica es posible y seguro. Nuestra experiencia inicial con este sellador de fibrina ha sido positiva, aunque probablemente se necesiten más casos y seguimiento para determinar el beneficio de esta técnica quirúrgica (AU)

Objective: To present our experience using an autologous fibrin sealant prepared with the Vivostat system® to control haemostasis without any renal parenchymal reconstruction. Material and methods: We performed 45 laparoscopic partial nephrectomies using this haemostatic agent. The surgical steps were: colon mobilization, identification of ureter, renal vessels and renal tumor, renal artery control with Rummel tourniquet, tumor excision with harmonic scalpel, application of fibrin glue to the resection bed twice (before and after kidney reperfusion). Patients were evaluated for acute or delayed bleeding. Results: Mean age was 63.9 years (33-80); mean tumor size was 2.5cm (1.5-4); mean operative time was 136.1min (90-180). Mean warm ischemia time was 19.2min (10-30). Mean blood loss was 97ml (50-300). Individual haemostatic stitches were performed before application of the sealant if acute bleeding was observed (14 cases). We did not achieve any case of postoperative bleeding from resection bed or renal failure. 1 patient required transfusion due to an abdominal wall haematoma. 65% were clear cell carcinoma, 10% were papillary carcinoma, 20% were oncocitoma. Free margin rate was 100%. Mean hospital stay was 4 days (2-6). Mean follow-up was 14 months (5-45). Conclusions: Excluding renorrhaphy during laparoscopic partial nephrectomy is feasible and safe. Our initial experience with the vivostat system in laparoscopic partial nephrectomy has been encouraging, but longer follow-up is needed to determine the real benefit of this surgical technique in laparoscopic partial nephrectomy (AU)

[Haemostasis control during laparoscopic partial nephrectomy without parenchymal renorrhaphy: the VIVOSTAT(®) experience]. / Control de la hemostasia durante la nefrectomía parcial laparoscópica sin renorrafia parenquimatosa: la experiencia Vivostat(®).

OBJECTIVE: To present our experience using an autologous fibrin sealant prepared with the Vivostat system(®) to control haemostasis without any renal parenchymal reconstruction. MATERIAL AND METHODS: We performed 45 laparoscopic partial nephrectomies using this haemostatic agent. The surgical steps were: colon mobilization, identification of ureter, renal vessels and renal tumor, renal artery control with Rummel tourniquet, tumor excision with harmonic scalpel, application of fibrin glue to the resection bed twice (before and after kidney reperfusion). Patients were evaluated for acute or delayed bleeding. RESULTS: Mean age was 63.9 years (33-80); mean tumor size was 2.5cm (1.5-4); mean operative time was 136.1min (90-180). Mean warm ischemia time was 19.2min (10-30). Mean blood loss was 97ml (50-300). Individual haemostatic stitches were performed before application of the sealant if acute bleeding was observed (14 cases). We did not achieve any case of postoperative bleeding from resection bed or renal failure. 1 patient required transfusion due to an abdominal wall haematoma. 65% were clear cell carcinoma, 10% were papillary carcinoma, 20% were oncocitoma. Free margin rate was 100%. Mean hospital stay was 4 days (2-6). Mean follow-up was 14 months (5-45). CONCLUSIONS: Excluding renorrhaphy during laparoscopic partial nephrectomy is feasible and safe. Our initial experience with the vivostat system in laparoscopic partial nephrectomy has been encouraging, but longer follow-up is needed to determine the real benefit of this surgical technique in laparoscopic partial nephrectomy.

Manejo de la masa suprarrenal: lo que el urólogo debe saber / Management of adrenal mass: What urologist should know

El incidentaloma suprarrenal es una entidad en aumento en la práctica clínica habitual debido al gran número de exploraciones radiológicas que se realizan. No existen guías clínicas publicadas sobre el manejo del incidentaloma suprarrenal apoyadas por ninguna sociedad científica. Toda masa suprarrenal debe ser estudiada para descartar malignidad o hipersecreción hormonal. Creemos que la patología suprarrenal quirúrgica debe ser manejada por el urólogo, por ser la especialidad que mayor relación tiene con en el retroperitoneo alto. El objetivo de esta revisión es desarrollar los aspectos fundamentales que el urólogo debe saber en el manejo de las masas suprarrenales. Conjuntamente con el servicio de endocrinología de nuestro hospital describimos los principales estudios a realizar ante el diagnóstico de una masa suprarrenal y el esquema terapéutico vigente en nuestro centro (AU)

Adrenal incidentaloma's prevalence is rising because of the big volume of radiologic explorations that we daily do. No comprehensive guidelines have been published by professional societies to guide the evaluation of patients with adrenal incidentalomas. All adrenal masses should be inspected for malignancy or hypersecreting disorders. In our point of view, adrenal surgery should be performed by the urologist, because it's the medical speciality which knows the best this anatomical region. The objective of this review is to present the main points that the urologist may know in the management of adrenal masses. Together with the department of Endocrinology of our hospital, we describe the main studies to perform in front of adrenal mass diagnosis and the current therapeutical diagram utilized in our center (AU)

[Management of adrenal mass: What urologists should know]. / Manejo de la masa suprarrenal: lo que el urólogo debe saber.

Adrenal incidentaloma's prevalence is rising because of the big volume of radiologic explorations that we daily do. No comprehensive guidelines have been published by professional societies to guide the evaluation of patients with adrenal incidentalomas. All adrenal masses should be inspected for malignancy or hypersecreting disorders. In our point of view, adrenal surgery should be performed by the urologist, because it's the medical speciality which knows the best this anatomical region. The objective of this review is to present the main points that the urologist may know in the management of adrenal masses. Together with the department of Endocrinology of our hospital, we describe the main studies to perform in front of adrenal mass diagnosis and the current therapeutical diagram utilized in our center.

[Surgical experience and results in transperitoneal laparoscopic adrenalectomy]. / Experiencia y resultados en la suprarrenalectomía laparoscópica transperitoneal.

INTRODUCTION: Laparoscopic adrenalectomy is currently the gold standard in surgical management of adrenal pathology. OBJECTIVES: To analyze our results after 12 years of experience in this surgery and to compare with the main published series. MATERIAL AND METHODS: we describe retrospectively 100 adrenalectomies performed between 1997-2009. Analyzed variables: age, size, side, preoperative diagnosis, operative time, blood loss, reconversion, hospital stay and histopathologic report. We utilized Fisher test and chi square test to compare categoric data. We utilized t-Student test to compare means from independent groups with normal distribution. We considered statistical significance when p<0.05. RESULTS: Mean age was 53.1 years (+/-14.4). Mean size was 3,7 cm (+/-2.2). In 51% of cases it was the left side. Mean follow-up was 15 months (+/-11.9). Preoperative diagnosis was: functional mass (44%), pheocromocytome (17%), incedentaloma>4 cm (20%), metastasis (10%) and adrenal carcinoma (5%). Mean operative time was 145.1 min (+/-55.6). Mean hematocrite loss was 6.26 points (+/-3.3). Reconversion rate was 9.6%. 2 cases of prolonged postoperative ileus. 2 patients required transfusion. 1 patient death because of an descompensation of liver cirrhosis. 80% of complications were on right side. Mean hospital stay was 6 days (+/-5.6). In last 30 procedures we realized statistical differences with first group, in terms of operative time (119.1 min vs 171.2 min) and hospital stay (4.1 days vs 6.1) (p<0.05). CONCLUSIONS: Transperitoneal laparoscopic adrenalectomy is a surgical feasible and safe procedure in urological groups with previous laparoscopic experience. Our results are similar with the published series and confirm the efficacy, security and reproducibility of this technique.

Experiencia y resultados en la suprarrenalectomía laparoscópica transperitoneal / Surgical experience and results in transperitoneal laparoscopic adrenalectomy

Introducción: La suprarrenalectomía laparoscópica es actualmente el gold estándar en el manejo quirúrgico de la patología suprarrenal. Objetivos: Analizar nuestros resultados tras 12 años de experiencia en esta cirugía y compararlos con las principales series publicadas. Material y métodos: Estudio descriptivo y retrospectivo. Análisis de 100 suprarrenalectomías realizadas entre junio de 1997 y junio de 2009. Se describen las siguientes variables: edad, tamaño, lateralidad, diagnóstico preoperatorio, tiempo quirúrgico, pérdida sanguínea, reconversión, complicaciones, estancia media y resultado anatomopatológico. Se utilizaron el test de Fisher y el test de chi cuadrado para comparar datos categóricos. Se utilizó el test t de Student para comparar medias de grupos independientes con distribución normal. Se consideró la significación estadística cuando p<0,05. Resultados: La edad media fue de 53,1 años (±14,4). El tamaño medio fue de 3,7cm (±2,2). En el 51% de los casos fue izquierda. La media de seguimiento fue de 15 meses (±11,9). El diagnóstico preoperatorio fue masa funcionante (44%), feocromocitoma (17%), incidentaloma mayor de 4cm (20%), metástasis (10%) y carcinoma suprarrenal (5%). El tiempo quirúrgico medio fue de 145,1 min (±55,6). El descenso medio de hematocrito fue de 6,26 puntos (±3,3). La tasa de reconversión fue del 9,6%. Hubo 2 casos de íleo postoperatorio prolongado. Dos pacientes requirieron transfusión. Uno murió en el postoperatorio por descompensación de cirrosis hepática asociada. El 80% de las complicaciones fueron en el lado derecho. La estancia media hospitalaria fue de 6 días (±5,6). En el grupo de los 30 últimos procedimientos se obtuvieron diferencias significativas en cuanto al tiempo quirúrgico (119,1 vs. 171,2min) y a la estancia media hospitalaria (4,1 vs. 6,1 días, p<0,05). Conclusiones: La suprarrenalectomía laparoscópica transperitoneal es una cirugía factible y segura en grupos con experiencia laparoscópica previa. Nuestros resultados se asemejan a las series publicadas en cuanto a la eficacia y a la morbilidad de la técnica (AU)

Introduction: Laparoscopic adrenalectomy is currently the gold standard in surgical management of adrenal pathology. Objectives: To analyze our results after 12 years of experience in this surgery and to compare with the main published series. Material & methods: we describe retrospectively 100 adrenalectomies performed between 1997–2009. Analized variables: age, size, side, preoperative diagnosis, operative time, blood loss, reconversion, hospital stay and histopathologic report. We utilized Fisher test and chi square test to compare categoric data. We utilized t-Student test to compare means from independents groups with normal distribution. We considered statistical significance when p<0.05. Results: mean age was 53,1 years (±14,4). Mean size was 3,7cm (±2,2). In 51% of cases it was the left side. Mean follow-up was 15 months (±11,9). Preoperative diagnosis was: functional mass (44%), pheocromocytome (17%), incedentaloma >4cm (20%), metastasis (10%) and adrenal carcinoma (5%). Mean operative time was 145,1min (±55,6). Mean hematocrite loss was 6,26 points (±3,3). Reconversion rate was 9,6%. 2 cases of prolonged postoperative ileus. 2 patients required transfusion. 1 patient death because of an descompensation of liver cirrhosis. 80% of complications were on right side. Mean hospital stay was 6 days (±5,6). In last 30 procedures we realized statistical differences with first group, in terms of operative time (119,1min vs 171,2min) and hospital stay (4,1 days vs 6,1) (p<0,05). Conclusions: Transperitoneal laparoscopic adrenalectomy is a surgical feasible and safe procedure in urological groups with previous laparoscopic experience. Our results are similar with the published series and confirm the efficacy, security and reproducibility of this technique (AU)

[Brachyterapy in localized prostate cancer]. / Braquiterapia en el cáncer de próstata localizado.

INTRODUCTION AND OBJECTIVES: Considering the high frequency of localized prostate cancer in stages, at the moment there are minimally invasive techniques that compete with the classic surgery. One of them is the Low Dose Rate (LDR) Brachytherapy with permanent implants of 1125 seeds. The objective of the present study is to expose our experience from the year 1998, when we made the first treatment, until today. The results and the morbidity of the patients over a 7 and a half years period are analyzed. MATERIAL AND METHODS: A total of 800 patients were treated with LDR brachytherapy, with average age of 68 years and range between 48 and 83 years. In all patients the 1125 seeds were used with Rapid-Strand and peripheral load by means of intraoperative planning. RESULTS: The urinary rate of complications was of 3% of AUR, and 0.2% of urinary incontinence. The morbidity on the digestive apparatus was of a 12% intermittent bleeding, 2% of proctitis, and a 0.3% of rectal fistulas.

Braquiterapia en el cáncer de próstata localizado / Brachytherapy in the localized prostate cancer

Introducción y objetivos: Teniendo en cuenta la alta frecuencia del cáncer de próstata en estadios localizados, existen actualmente técnicas mínimamente invasivas que compiten con la cirugía clásica. Una de ellas es la Braquiterapia de Baja Tasa de Dosis con implantes permanentes de semillas de Yodo-125. El objetivo del presente trabajo es exponer nuestra experiencia desde el año 1998 en que realizamos el primer tratamiento hasta el día de hoy. Se analizan los resultados y la morbilidad de los pacientes con un seguimiento de 7 años y medio. Material y Métodos: Un total de 800 pacientes fueron tratados con Baja Tasa de Dosis, con edad media de 68 años y rango entre 48 y 83 años. En todos los pacientes las semillas de I125 fueron utilizadas con Rapid-Strand, con técnica de carga periférica y mediante planificación intraoperatoria. Resultados: La tasa de complicaciones urinarias fueron del 3% de RAO, y del 0,2% de incontinencia urinaria. La morbilidad sobre el aparato digestivo fue de un 12% de sangrados intermitentes, 2% de proctitis, y un 0,3% de fístulas rectales

Introduction and objectives: Considering the high frequency of localized prostate cancer in stages, at the moment there are minimally invasive techniques that compete with the classic surgery. One of them is the Low Dose Rate (LDR) Brachytherapy with permanent implants of I125 seeds. The objective of the present study is to expose our experience from the year 1998, when we made the first treatment, until today. The results and the morbidity of the patients over a 7 and a half years period are analyzed. Material and methods: A total of 800 patients were treated with LDR brachytherapy, with average age of 68 years and range between 48 and 83 years. In all patients the I125 seeds were used with Rapid-Strand and peripheral load by means of intraoperative planning. Results: The urinary rate of complications was of 3% of AUR, and 0.2% of urinary incontinence. The morbidity on the digestive apparatus was of a 12% intermittent bleeding, 2% of proctitis, and a 0.3% of rectal fistulas

[Proteases and prostatic disease: cytosolic cathepsin D]. / Proteasas y patología prostática: la catepsina D citosólica.

OBJECTIVE: Cytosolic cathepsin D is a recognized predictor in breast cancer. This study was conducted to determine its behaviour in benign prostatic hyperplasia (BPH) and prostate cancer. The changes according to prostate volume, its relation with other serum markers (PSA, PAP, etc.) in regard to tumor grade, stage and survival were analyzed. METHODS: The study was carried out on 376 patients with prostatic disease that had been diagnosed from 1991-1996. Determination of cytosolic cathepsin D levels was performed on all samples of prostate tissue according to the CIS BioInternational Immunoradiometric study. RESULTS: Cathepsin D values ranged from 0.2 to 86.5 pmol/mg (mean 14.9) in patients with BPH and higher values were found for prostates with a larger volume (p = 0.004). A significant difference was found between patients with and those without a bladder catheter (p = 0.024); values were higher in the former group of patients. Cathepsin D values ranged from 0.5 to 74 pmol/mg (mean 18.13) in patients with prostate cancer. A statistically significant difference was found between the mean values of patients with prostate cancer and those with BPH (p = 0.047). In patients with prostate cancer, a significant difference was also found between patients with and those without a catheter (p = 0.04). No relationship was found between cathepsin D and the other parameters analyzed. CONCLUSIONS: As in most of the literature reviewed, cytosolic cathepsin D was not found to be a predictor in prostate cancer. Furthermore, no correlation was found between cathepsin D and the other markers analyzed. The foregoing may be due to the small number of tumor samples and short follow-up.

[Artificial sphincter implantation in women with urinary incontinence using a combined abdomino-vaginal approach]. / Implantación del esfínter urinario artificial en la mujer con incontinencia urinaria por vía combinada abdomino vaginal.

OBJECTIVE: The artificial sphincter has been utilized for urinary incontinence due to intrinsic sphincteric insufficiency, with good fixation of the urethra and a maximum urethral closing pressure of 20-30 cms H2O, or after failed attempts at correction using other techniques. This procedure is difficult to perform since the patients have generally undergone several operations and it is necessity to prepare the cleavage between the urethra and vagina. We propose a modified combined vaginal and suprapubic approach of the technique described by Appell and Abbassian in 1988 for enhanced exposure of the urethra and bladder neck and easy access. METHODS: The modified combined abdominovaginal approach has been utilized in 18 females aged 16-62 years since 1995. RESULTS: 16 patients were continent (88%). One patient (5.5%) required removal of the artificial sphincter due to infection. Another patient (5.5%) has mild incontinence and requires 2 pads a day. Four patients (22%) with detrusor instability are receiving anticholinergics. Three patients (16%) with an underlying neurogenic incontinence require intermittent catheterization. Fourteen patients (77.7%) have type III stress urinary incontinence. We performed the Kelly procedure in 10 patients (55.5%), the Marshall-Marcetti-Kranz in 7 (38.8%), Gittes in 3 (16.6%), and 2 patients (11.1%) had a sling procedure. Two techniques were simultaneously performed in some patients. CONCLUSIONS: Although the number of patients in this series is small, the fact that only one case required removal of the artificial spincter due to infection indicates that this is a useful alternative approach that significantly facilitates implantation of the artificial sphincter in these patients.

[Ultrasonographic diagnosis of Fournier's gangrene]. / Diagnóstico ecográfico de gangrena de Fournier.

OBJECTIVES: The usefulness of ultrasound in the detection of Fournier's gangrene in the early stages is described herein. METHODS/RESULTS: We discuss the clinical course of the patient with scrotal inflammation of a torpid course suspected as Fournier's gangrene on the ultrasound findings. CONCLUSIONS: The use of ultrasound in cases with acute scrotal inflammation of a torpid course as in this case, permits early detection of Fournier's gangrene, a fulminant condition. A review of the literature has shown that the findings described herein have been infrequently reported.

[Urethral protrusion caused by blunt trauma of the anterior urethra]. / Protrusión uretral por traumatismo cerrado de uretra anterior.

We report an uncommon case of complete rupture of the anterior urethra secondary to blunt trauma, with protrusion of the urethral mucosa through the urinary meatus. The singular images of this case are presented and the mechanisms involved in this unusual type of lesion are analyzed.

Granulomatous prostatitis.

Twenty cases of granulomatous prostatitis are presented. They were identified, histologically or cytologically, among 1,316 patients with prostatic pathology at the General Hospital of Asturias during a period of 3 years (Jan. 1984 to Dec. 1986). The etiology, histogenesis, clinical and morphological aspects, treatment and prognosis of the different types of granulomatous prostatitis, according to a classification by the authors, are discussed. The significance of the differentiation of granulomatous prostatitis from carcinoma is discussed. Fine-needle aspiration cytology (Franzen) is recommended as the diagnostic method of choice.