[Changes in frequency of external office visits for diseases. Analysis of trends in 6 years]. / Cambios en la frecuentación de patologías en consulta externa. Análisis de la evolución en 6 años.

INTRODUCTION: In 1996 we made a rate frequency analysis of attended pathologies in extern office. Along these years, we have made different actuations about some pathologies like HBP and vasectomy. OBJECTIVES: To know the results of these measures after 6 years, in 2002. MATERIAL AND METHODS: Different pathologies frequency is analyzed in extern office of Urology in 2002 and the results are compared with those we got before making the remake of the action about the mentioned cases. RESULTS: The remake in the treatment of the vasectomy and HBP let us to have a 15% and 1.2% more of first visits in extern office respectively. While the first visits because of suspicion of prostatic cancer has been increased in 25%. Visits because of pathologies like hematuria, renal colic, cystitis and impotency have been increased importantly (56.4%, 51.9%, 61.1% and 17.8%). CONCLUSIONS: The remake of actions on pathologies is a efficacious tool in the management of an Urology Area. Its analysis let us to value the benefits we have got and to detect new problems that appear.

Cambios en la frecuentación de patologías en consulta externa. Análisis de la evolución en 6 años / Frequency changes of attended pathologies in extern office. Evolution analysis in six years

INTRODUCCIÓN: En 1996 realizamos un análisis de la tasa de frecuentación de patologías atendidas en la consulta externa. A lo largo de estos años hemos realizado diversas estrategias de actuación sobre algunas patologías o entidades como la HBP y la contracepción masculina. OBJETIVOS: Conocer el resultado de dichas medidas pasados 6 años, en el año 2002. MATERIAL Y MÉTODO: Se analiza el porcentaje de las distintas patologías vistas en consulta externa de la Unidad de Urología en el año 2002, y se comparan los resultados con los obtenidos antes de haber realizado el rediseño de la actuación sobre los casos mencionados. RESULTADOS: El rediseño en el manejo de la contracepción masculina y de la HBP ha permitido disponer de un 15 por ciento y un 1,2 por ciento más de primeras visitas en consulta externa respectivamente, mientras que se ha incrementado un 25 por ciento la consulta por sospecha de cáncer prostático. Se aprecian importantes incrementos de consultas por patologías como la hematuria (56,4 por ciento), crisis renoureteral (51,9 por ciento), síndrome miccional (61,1 por ciento) e impotencia (17,8 por ciento). CONCLUSIONES: El rediseño de la actuación sobre patologías es una herramienta eficaz en la gestión de una Unidad de Urología. Su análisis permite valorar los beneficios conseguidos y detectar nuevos problemas que surgen (AU)

[Analysis of the delay in surgical treatment of adenocarcinoma of the prostate]. / Análisis de la demora en el tratamiento quirúrgico del adenocarcinoma de próstata.

INTRODUCTION: The prostate cancer is an important cause of men's mortality in our society. PURPOSE: To know the time of delay in to realise the surgical treatment of the prostate cancer. MATERIALS AND METHODS: Analysis of 30 cases of patients treated with radical prostatectomy, cuantifying the time of delay in all the periods of the process. RESULTS: Appointment in general practitioner-first appointment in urology: 21.7 days. First appointment in urology-biopsy: 22.8. Biopsy-diagnosis: 34.3. Diagnosis-appointment of anesthesiology: 28.5. Anesthesiology-radical prostatectomy: 25.7. CONCLUSIONS: There are actions for to reduce the delay in to perform the diagnosis or treatment, where we can act how an improvement plan: to give poblational education in general and information to the patient in particular, to analyze the rules of medical action, to improve the coordination between level, to improve the flexibility in outpatients appointment and time waiting for diagnosis test and treatment, to correct the temporality, to create clinical units of many specialties and to improve the politics of health.

Análisis de la demora en el tratamiento quirúrgico del adenocarcinoma de próstata / Time of delay analysis of surgical treatment of the prostate cancer

INTRODUCCIÓN: El cáncer de próstata es una causa importante de mortalidad masculina en nuestro medio. OBJETIVOS: Conocer el tiempo de demora existente en realizar el tratamiento quirúrgico del adenocarcinoma de próstata. MATERIAL Y MÉTODO: Análisis de 30 casos de pacientes tratados mediante prostatectomía radical, cuantificando los diversos tiempos de demora existentes en las distintas fases del proceso. RESULTADOS: Visita en atención primaria-primera visita en especializada: 21,7 días. Primera visita en especializada-realización de biopsia: 22,8 días. Biopsia-información de diagnóstico: 34,3 días. Diagnósticovisita preanestésica: 28,5 días. Preanestesia-intervención quirúrgica: 25,7 días. COMENTARIOS: Como puntos de importancia en una posible demora diagnóstica-terapéutica, donde podemos actuar como plan de mejora destacamos: la educación poblacional en general y la información al paciente en particular, análisis de las pautas de actuación médica, mejora de la coordinación interniveles, aumento de la flexibilidad en consultas y listas de espera diagnósticas y terapéuticas, corrección de la temporalidad, creación de unidades clínicas multidisciplinarias, y mejora en las políticas sanitarias (AU)

Aumento de la tasa cruda de la incidencia del cáncer de próstata en nuestro medio / Increase of the crude rate of the incidence of prostate cancer un our population

El cáncer de próstata es uno de los cánceres más frecuentes en el sexo masculino, y su incidencia está aumentando progresivamente en una población que cada vez tiene una edad media más elevada. OBJETIVOS: Conocer la tasa cruda de la incidencia del cáncer de próstata en nuestra población y conocer si ésta progresa. MATERIAL Y MÉTODO: Conociendo el número de habitantes que cubre nuestra asistencia, se analiza el número de casos de cáncer de próstata diagnosticados según el archivo de Anatomía Patológica. RESULTADOS: La tasa cruda de la incidencia del cáncer de próstata en nuestro medio es de 28,7 casos/100.000 habitantes, y ésta crece progresivamente en torno a 3 casos/100.000 h/año. CONCLUSIONES: Existe un aumento de la tasa cruda de la incidencia del cáncer de próstata, influido probablemente por el aumento de la edad poblacional y la extensión de la medida de PSA en pacientes con sintomatología de afección prostática (AU)

[Crude rate increase of prostate cancer incidence in our setting]. / Aumento de la tasa cruda de la incidencia del cáncer de próstata en nuestro medio.

UNLABELLED: The prostate cancer is one of the most frequent cancers in the male sex and its incidence is increasing progresively in a population that every time has a more increased age. OBJECTIVE: To know the crude rate of prostate cancer in our population and if there is an increase. MATERIAL AND METHODS: Knowing the number of habitants under our assistance, we analyze the cases diagnosed of prostate cancer. RESULTS: The crude rate of the incidence of prostate cancer in our medium is 28.7 cases/100.000 habitants/year and this increases progressively in 3 cases/100.000 habitants/year. CONCLUSIONS: There is an increase of the crude rate of the incidence of prostate cancer probably by the influence of the increase of the population's age and the generalization of the measure of PSA in simtomatic patients of prostatic disease.

[Economic impact of complications after transurethral resection of the prostate on its cost throughout the process]. / Impacto económico de las complicaciones de la resección transuretral de próstata en su coste por proceso.

INTRODUCTION: Considering that BPH is a highly common condition in the urological practice, that demographic changes further emphasise this feature and that the analysis of costs, funding and health care management are becoming increasingly under scrutiny, it is important to know the cost per procedure of the most commonly used therapeutical approaches and the impact of the complications on such cost. OBJECTIVES: 1. To know the cost per procedure of prostate TUR as PBH treatment. 2. To know the percentage of complications involved and the way in which they impinge on cost. MATERIAL AND METHOD: Considering all data gathered from the annual surgical activity in our service with regard to this procedure and the percentage of complications after studying 105 cases over an evolution period of 6 to 50 months, the Planning and Management control Unit at the H.C.S. reported on the expenditure generated by this activity. RESULTS: The cost per procedure in prostate TUR due to BPH in our environment is 191.030 pesetas at 1997 value. Morbidity affects 23% patients. Diagnosis and treatment of complications increases the overall cost by 7% thus reaching 205.096 pesetas. CONCLUSIONS: The knowledge of the above results provides important data on the expenditure generated by the activity of our Service for funding and management purposes. It also allows us to perceive therapeutical results as a measure of quality control, and to redefine those actions that will allow us to improve our results.

[Local anesthesia in meatoplasty with pediculated flap, an efficient technique in the treatment of meatal stenosis]. / La anestesia local en la meatoplastia con colgajo pediculado, una técnica eficiente en el tratamiento de la estenosis de meato.

Meatal stricture is not an uncommon condition in the clinical practice, the classical treatment being meatotomy. The failure of the technique and the changes in the quality of the urinary stream have forced us to perform a meatoplasty procedure with pedicle flap from penial skin as described by Jordan, using intravenous local anaesthetics, thus avoiding hospitalization and reducing the overall cost of the procedure. From a total of 23 patients who (between May 1995 and April 1998) required surgery due to meatal stricture, 11 patients underwent meatoplasty and the rest meatotomy. None of the patients in the former group developed re-stenosis, and achieved a mean improvement of Q max in the flowmetry performed three months after the procedure of 23 mL/sg. vs the 10.5 mL/sg. of patients undergoing meatotomy. This difference is statistically significant at p = 0.02. Cost saving when surgery is conducted in the day hospital is 122,302 pts/procedure vs 215,182 pts/procedure if the patient had to remain in hospital for 3 or 7 days. Compared to the lower cost of meatotomy (39,308 pts/proc.) or meatoplasty (57,525 pts/proc.), it must be emphasised that the management of complications in the first case is 6,816 pts/patient vs 1,724 pts/patient required for cures in the case of Jordan's technique. It was concluded that pedicle flap meatoplasty is an efficient and definitive technique in the treatment of meatal stricture.

[Epidermoid cyst of the testis. A case of difficult preoperative diagnosis]. / Quiste epidermoide de testículo. Un caso de diagnóstico preoperatorio difícil.

Epidermoid cysts os the testes have an incidence between 1-2% of total tumours in that organ. The embryonary origin of this benign neoplasia is unknown, although the most widely accepted theory is they are monodermal teratomas. Differential diagnosis with germinal cells is established through the characteristic dartboard-like ultrasound image, which allows testicular conservant surgery though only in the case of certainty about the lesion. Since that was not the case and given the ultrasound variability recorded in the literature, radical orchiectomy was performed to overcome the persistent doubt at staging the tumour's benignancy.

[Shared care in BPH. First national experience]. / Cuidados compartidos en HBP. Primera experiencia nacional.

The high prevalence of Benign Prostate Hyperplasia and the increased demand for care of this condition, should compel us to plan for shared care models in parallel to Primary Care, in the way it has happened with entities such as HBP and Diabetes. The set of measurements to be adopted when sharing services with primary care is known as "shared care". This paper presents the first national experience of "shared care" with primary care in BPH. The project has consisted in a series of steps to increase awareness, train and make available for family physicians, a clinical practice guide defining the criteria for initial evaluation, medical treatment and referral of patients to Urology surgeries, including with the referral document the appropriate diagnostic tests. A Quality Commission has been created to study the level of compliance of the documentation used for referral to the specialist and the clinical histories of patients treated in primary care. The results obtained are significant and most studies carried out fulfill the requirements in 60% cases, which has allowed to reduce overcrowding in the Urology outpatient offices (4200 surgery visits saved/year in our environment), has provided easy access of patients to adequate diagnosis and treatment, as well as significant financial savings (30 million pesetas/year). In short "shared care" is a reality in our environment that allows a more effective, fast medical assistance and improved access to specialist care by reducing the demand of specialized surgery hours.

[Rate of external consultation utilization. Organizational and managerial basis of a urology service]. / Tasa de frecuentación de consulta externa. Base organizativa y de gestión de un servicio de urología.

INTRODUCTION: The frequency of visits to an outpatients office is indicative of the proportion of population to be served at that location. MATERIAL AND METHOD: Analysis of the frequency of new cases to an outpatients office over one year and correlation with the conditions treated over the corresponding period. OBJECTIVES: To know the overall frequency of new cases, by condition, affected organ and group of diseases. To know the percentage of surgical resolution of those conditions. To infer from these data the resources necessary in terms of offices, operating theatres and staff RESULTS: The outpatients office shows an overall frequency of new cases of 124/10000 people/year. The highest frequencies by condition, affected organ and group of diseases correspond to BPH, inguinoscrotal area and andrology. 35% of all new cases are managed surgically. 17.5% BPHs and 16.4% prostate carcinomas undergo surgery. The necessary resource are inferred to be: 1.5 ambulatory operating theatres/week, 2-2.5 central operating theatres/week. 5-6 office visits/week and 3 urologists. CONCLUSIONS: The study on the frequency of visits to the outpatients office is a useful tool for the organization and management of the Urology Service.

[Ureteral metastasis of renal parenchyma tumor]. / Metástasis ureteral por tumor del parenquima renal.

Metastatic involvement of the ureter due to renal parenchyma neoplasia has been reported in a total of 53 cases in the literature, the described mechanisms for tumoral spread being: haematogenic, lymphatic, canalicular and direct. Time to appearance of metastasis is far from prompting agreement among the authors in terms of its synchronous or metachronous nature. The most frequently reported symptoms are total and painless haematuria, and obstructive uropathy: CAT, percutaneous nephrostomy (for locally advanced disease) and endoscopy, are the most frequently used diagnostic tools. The only available therapy is nephrouretectomy for a diagnosis synchronous with the primitive tumour, and uretectomy for metachronous emergence. This paper reports on a case of sarcomatoid renal tumour with ipsilateral synchronous involvement of the ureter, which caused an obstructive uropathy treated by nephrouretectomy.

[Protocol for coordination with primary care: a new working system in urology. Validation]. / Coordinación protocolizada con la asistencia primaria: nuevo sistema de trabajo en urología. Su validazación.

BACKGROUND: The Urology Unit at the Costa del Sol Hospital works in coordination with the primary health care network using diagnostic and therapeutic protocols. OBJECTIVES: To know whether the system is effective based on the analysis of the quality of patient referral to Hospital according to the performance of family doctors. MATERIAL AND METHOD: The referral document summarising the study conducted by the family doctor is analyzed. 578 correspond to conditions already coordinated and 269 to other situations not yet covered by the system. RESULTS: For the coordinated conditions, 29% referrals are high quality and 45.9% are poor. For non-coordinated conditions however, 9.2% are high quality and 57.7% poor. The difference is statistically significant (p < 0.001). CONCLUSIONS: Work in coordination with primary health care is feasible, effective and probably cost-efficient.

[Short hospital stay in the treatment of benign prostatic hyperplasia using transurethral resection]. / Estancia hospitalaria corta en el tratamiento de la HPB mediante RTU.

INTRODUCTION: Prostate TUR is the most common approach used in the surgical management of BPH. The highest expenditure portion of this treatment occurs during the post-operative. PATIENTS AND METHOD: 42 cases of prostate TUR were analyzed by GRD type, prostate weight, hospital stay and complications in the peri- and post-operative periods. Both the approach used and the degree of patient's satisfaction are analyzed. RESULTS: Mean prostate weight is 46 g (range 23-69). 45% cases involve GRD 336 and 55% GRD 337. Mean hospital stay for the procedure was 2.5 days. 2.3% of the series developed long-lasting temperature, 2.3% required transfusion and 2.3% a second intervention. Around 81% patients are satisfied with the results. CONCLUSIONS: It is possible to reduce costs by reducing hospital stay without impairing care quality and patient satisfaction.

[An analysis of the prognostic factors in renal-cell carcinoma]. / Analisis de factores pronósticos en el carcinoma de células renales.

OBJECTIVES: The study proposes the analysis of the influence of gross, microscopical and clinical pathoanatomical prognostic factors in the survival of patients with RCC through univariance and multivariance statistical analysis, and its global evaluation as a predictive model. PATIENTS AND METHOD: The study involved 218 RCC cases operated on over 20 years, with a mean follow-up of 60 months. RESULTS AND CONCLUSIONS: All prognostic factors studied have a significant influence on the survival. When studied jointly, they include separately and in order of significance the metastatic involvement, mitotic index, cava vein involvement, nuclear grade and sarcomatoid histologic pattern. Also, we confirm that considered jointly they conform a valid predictive model.

[Renal-cell carcinoma and polycystic disease in an adult]. / Carcinoma de células renales y enfermedad poliquística del adulto.

Polycystic disease of the adult is the most common presentation of renal cystic disease and is transmitted by dominant autosomic heredity. Development of renal cell carcinoma has been reported within this cystic disease, but the frequency of such coincidence is not higher than in the remaining population. Most of these tumours are found incidentally and may involve a diagnostic problem due to the marked distortion of the kidney's architecture produced by the polycystic disease of the adult.

[Molluscum contagiosum in immunodepressed patient]. / Molusco contagioso en paciente inmunodeprimido.

Molluscum contagiosum is a skin lesion caused by a poxviridae virus. Infection in children takes place through cutaneous contact while in adults results from sexual contact or under immunosuppression conditions. In immunosuppressed patients this infection is caused by opportunistic microorganisms and, basically, its appears when CD4 levels reach a certain decline, therefore its presence can be considered as a marker for poor prognosis or advanced stage of the disease.

[Primary transitional cell carcinoma of the prostate. An infrequent tumor]. / Carcinoma transicional primario de próstata. Un tumor infrecuente.

Primary prostatic carcinoma accounts for 2% to 4.5% of all neoplasias to this organ, and it has been observed in 2.8% of all radical cystoprostatectomies performed in the Mayo clinic. It originates in the poorly differentiated reservoir cells of the prostatic periurethral ductus which explains why diagnosis is most often obtained in advanced stages (stromal involvement), thus limiting its management to radical surgery. This paper contributes one case report of a patient diagnosed by transrectal biopsy of a primary prostatic transitional carcinoma presenting with incoercible rectorrahges and urinary obstruction symptoms. Treatment was through pelvic exenteration, and urinary and gut by-pass.

[Abdominal paragangliomas. The experience of the Hospital 12 de Octubre]. / Paragangliomas abdominales. Experiencia del Hospital 12 de Octubre.

This is a revision of our experience between 1975 and 1992 over a total of 35 patients who underwent surgery in 40 occasions for pheochromocytoma. If we dismiss one case of pheochromocytoma with early metastatic malignant presentation and which was not removed, a total of 6 patients with abdominal paraganglioma (17%) have undergone surgery in 10 occasions. Three of them (50%) were multiple and recurrent, an one (16%) become malignant after multiple recurrences. Average age was 34.6 years with balanced sex distribution. No patient had neurofibromatosis, Von Hippel Lindau disease, MEN syndromes or Carney's triad and only one case, which corresponded to the malignant pheochromocytoma, showed direct familial background. All patients were hypertensive. Four cases (66%) presented with catecholamine crisis, one case was an incidentaloma that at the 24-hour monitoring presented hypertensive crisis during the sleep, and the last one was diagnosed while investigating a case of sustained HTA in a young female. All patients had high urinary catecholamine excretion. To establish location of the tumour MIBG scanning (90% sensitivity) was used in first place followed by guided CT (80% sensitivity) since both techniques have a good correlation in order to design the surgical approach. Angiography was reserved for cases where the other two techniques were inconclusive or when it was necessary to obtain a better profile of the surgical anatomy. A total of 15 paraganglioma were removed, the most frequent location being renal parahilar (26%) followed by preaortic in Zuckerkandl's organ (20%) and vesical (20%). The most relevant intraoperative complications were HTA crisis related to anaesthetics manoeuvres and tumoral handling (90%), and hypotension following tumour exercises (10%). During the postoperative period, three patients required blood transfusion and one of them had to be re-intervened for bleeding caused by unnoticed damage to the right renal vein. Currently, three patients (50%) are disease free, one with residual mild HTA controlled with diuretics. Two patients (33%) are awaiting for re-intervention due to recurrence (one with multiple extra-abdominal recurrence) after one and two prior interventions respectively. The last one (16%) is the malignant pheochromocytoma, operated four times for recurrence which currently shows lung metastasis with adequate drug control of clinical manifestations, after polychemotherapy failure and 27-months follow-up since metastasis has been detected. Revision of existing literature and discussion of issues related to signs and symptoms, diagnosis, surgical preparation and approach, as well as prognostic implications related to paraganglioma as compared with adrenal-located pheochromocytoma.

[Intradiverticular bladder tumors]. / Tumores vesicales intradiverticulares.

Retrospective study conducted on 58 patients with vesical diverticulum seen in our unit between 1975 and 1992, of which a total of 11 (18.9%) patients had vesical tumours. Of these, 6 (10.3%) were intradiverticular and 5 (8.6%) extradiverticular. Sixty-six percent of patients with intradiverticular tumours also had prior or concurrent history of extradiverticular vesical tumours. The most frequent clinical presentation was gross haematuria. The abdomino-pelvic CT is the most sensitive morphological examination although in 33% cases it resulted in overstaging. Curative treatment was only possible in the 4 patients with urothelial tumours, in whom 3 partial cystectomies with pelvian lymphadenectomy (2 pT1 G2 and 1 pT3 G3) and 1 TUR (T1 G2) were performed. The 2 (33%) remaining patients had advanced locoregional epidermoid carcinoma (T4 N+). All patients with urothelial carcinoma are alive with follow-up ranging between 6 months for the one infiltrant case and 136 months for a surface tumour undergoing partial cystectomy. Prognosis for both epidermoid carcinoma was ominous with mean survival time of 9 months. Review of the literature and discussion of epidemiological, clinical, diagnostic, therapeutic and prognostic issues.