Nefrectomía radical laparoscópica en angiomiolipoma renal con invasión de vena renal / Laparoscopic radical nephrectomy of angiomyolipoma with renal vein involvement

Background: Angiomyolipomas associated with tuberous sclerosis may invade the renal vein and generate intramural thrombi. Case report: We report a 36-years-old woman, consulting for left flank pain. CT scan showed a large tumor in the left kidney consistent with the diagnosis of infiltrating renal angiomyolipoma with tumor invasion of the vein. Laparoscopic nephrectomy was performed, with removal of tumor thrombus. The operative time was 127 minutes and estimated bleeding 20 ml. There were no intraoperative or postoperative complications. The patient is currently asymptomatic after 12 months of follow up. The pathological study of the surgical piece showed a renal angiomyolipoma with invasion of the kidney and a solid tumor in the lumen of the renal vein.

Objetivo: Se presenta el caso clínico de un Angiomiolipoma renal con extensión a vena renal, patología de muy baja frecuencia. Caso clínico: Mujer de 36 años, quien consulta por dolor en flanco izquierdo. En una tomografía computada se encuentra una lesión tumoral extensa del riñón izquierdo compatible con un Angiomiolipoma renal infiltrante e invasión tumoral de la vena renal. Se realiza nefrectomía laparoscópica, con extirpación de trombo tumoral. El tiempo operatorio fue de 127 min y el sangrado estimado de 20 ml. No hubo complicaciones intra ni postoperatorias. La paciente se encuentra actualmente asintomática luego de 12 meses de seguimiento. La histología mostró un Angiomiolipoma renal con invasión del riñón y un tumor sólido en el lumen de la vena renal. Conclusión: La invasión de vena renal por un Angiomiolipoma es extremadamente raro. Su resolución laparoscópica es posible, con sólo una comunicación previa en la literatura.

Valor de la secuencia de difusión en el estudio de cáncer de próstata en pacientes con antígeno prostático específico elevado / Value of diffusion-weighted sequences in the study of prostate cancer in patients with increased prostate specific antigen levels

En el carcinoma prostático la arquitectura glandular es reemplazada por células cancerosas, produciendo barreras al movimiento del agua, que pueden ser estudiadas con resonancia magnética potenciada en difusión. Para evaluar el aporte de estas secuencias en el estudio de la próstata, realizamos estudio descriptivo e inferencia!, utilizando difusión en 26 pacientes con tacto rectal anormal y antígeno prostático elevado. Se analizó sensibilidad, especificidad y curvas ROC basadas en coeficiente aparente de difusión (CAD). Se realizó biopsia prostática en 14 pacientes; 7 resultaron positivos. Con CAD <1000 um2/s, se encontraron altas sensibilidades con bajas especificidades y valores predictivos moderados. Incorporando T2 mejoraron: certeza diagnóstica, especificidad y valores predictivos. Al comparar los valores CAD en zonas con y sin cáncer, obtuvimos diferencias para CAD promedio y mínimo. Las curvas ROC mostraron áreas elevadas y significativas, sugiriéndose valores de corte de 1059 um2/s y 969 um2/s entre "normales" y con cáncer; LR(+) para valores de corte: 6,97 y 5,23 respectivamente. Nuestros resultados permiten proponer que se obtiene mayor ganancia diagnóstica en la interpretación conjunta de imágenes T2 y secuencias de difusión y que CAD permite diferenciar entre tejido normal y cáncer, por lo que se debiera incorporar en el estudio prostático.

In prostatic carcinoma, the glandular architecture is replaced by cancer cells producing barriers to water motion, anomaly that can be studied through diffusion-enhanced MRI technique. To assess the contribution of these sequences in the prostate cancer exploration, we conducted a descriptive and inferential study using diffusion-enhanced MRI technique in 26 patients with abnormal digital rectal examination (DRE) and increased prostate specific antigen (PSA) values. We analyzed sensitivity, specificity and ROC curves based on apparent diffusion coefficient (ADC). Seven out of 14 biopsies were positive in patients undergoing prostate biopsy. When applying ADC <1000 _m2/se, high sensitivity with low specificity levels, as well as moderate predictive values were obtained. By incorporating T2-weighted images, improved diagnostic accuracy, specificity and predictive values were achieved. When comparing ADC values in tissues with and without cancer, average and minimum ADC appeared to exhibit different values. ROC curves depicted increased and significant values, suggesting cutoff values of 1059 um2/s and 969/um2/s for healthy and malignant tissues, respectively; LR (+) for cut-off value: 6.97 and 5.23, respectively. Our results enable us to propose that improved diagnostic outcomes are attained through combined interpretation of T2-weighted images and diffusion-weighted sequences and that the ADC permits discrimination between normal and malignant tissues. Therefore, we strongly support that these criteria should be taken into account when performing prostate explorations.

Splenic abscess complicating infective endocarditis: three case reports.

We present three case-reports of splenic abscess in patients who were initially diagnosed with bacterial endocarditis. In all cases the diagnosis of splenic abscess was based on the findings of abdominal CT scan or MRI. All patients were treated by laparotomy and splenectomy. Two patients fully recovered and one patient, who suffered from splenic rupture and massive blood loss before surgery, died. Splenic abscess is a well-described but rare complication of infective endocarditis. Rapid diagnosis and treatment are essential as its course can prove fatal. Abdominal CT scan or MRI should be performed if there is clinical suspicion of splenic abscedation. Immediate splenectomy combined with appropriate antibiotics and valve replacement surgery is the treatment of choice. Splenic tissue is very fragile--especially if the abscess is located subcapsular--and a splenic rupture can result from minimal trauma. If the patient's general state allows it, it is best to perform splenectomy prior to valve replacement surgery to prevent re-infection of the valve prosthesis. A combined one-stage procedure is also an option.

Nefrectomía parcial: una alternativa real de tratamiento en tumores renales / Partial nephrectomy: an alternative for the treatment of renal tumors

La imagenología ha sido fundamental en la detección de tumores renales, muchos de ellos menores a 4 cm en los cuales una resección parcial permite un tratamiento efectivo. En nuestro servicio se le ofrece una nefrectomía parcial a pacientes monorrenos, con tumores bilaterales, con una función renal límite y a aquellos que presenten tumores de 4 cm o menos. Presentamos nuestra experiencia en 37 casos de nefrectomías parciales operados entre agosto de 1995 y agosto del 2003. La edad media fue de 61 años y el tamaño promedio de los tumores fue de 4,7 cm. La hospitalización fue de 3,9 días en promedio. La única complicación aguda fue una hematuria persistente que requirió reexploración. Como complicación tardía se evidenció la progresión de una insuficiencia renal ya presente antes de la cirugía en un paciente. El seguimiento medio fue de 43 meses. Hasta el momento no han aparecido lesiones sugerentes de recidiva de la enfermedad. En nuestra opinión este procedimiento es seguro, no determina mayor morbilidad que una nefrectomía radical y permite un éxito oncológico similar.

Cateterización ureteral anterógrada: una indicación actual / Antegrade ureteral catheterization: a present indication

Existen situaciones de obstrucción del tracto urinario superior, en las cuales no es posible la cateterización ureteral en forma retrógrada (forma clásica) y se hace necesario realizar una nefrostomía. La instalación de un catéter pigtail en forma anterógrada, utilizando la vía percutánea, logra un adecuado drenaje de la vía urinaria, evitando así la necesidad de una nefrostomía. En este trabajo exponemos nuestra experienciaal instalar 10 catéteres ureterales tipo pigtail en 6 pacientes, vía percutánea y describiendo la técnica utilizada. Concluimos que esta técnica logra un adecuado drenaje de la vía urinaria, es segura y da una mejor calidad de vida, la que puede ser realizada en forma ambulatoria.

[Usefulness of free prostate specific antigen in the detection of prostate cancer]. / Utilidad de la fracción libre del antígeno prostático específico en la detección del cáncer de la próstata.

BACKGROUND: The predictive value of prostate specific antigen for prostate cancer, when levels are between 4 and 10 ng/ml, is low. Within these range of values, some authors recommend the measurement of the free fraction of the antigen to improve its predictive capacity. AIM: To evaluate the predictive value of the free fraction in subjects with prostate specific antigen values between 4 and 10 ng/ml. PATIENTS AND METHODS: One hundred and forty subjects with prostate specific antigen between 4 and 10 ng/ml were evaluated. All were subjected to transcrectal ultrasound examination with biopsies and the free fraction of the antigen was measured by enzyme immuno assay. RESULTS: Cancer was diagnosed in 36 subjects, all others had a benign prostatic hyperplasia. Mean prostate specific antigen values were 7.4 and 7.1 ng/ml in patients with cancer and hyperplasia, respectively. The percentage of free prostatic specific antigen was 9.8 and 19.8% in subjects with cancer and hyperplasia respectively (p < 0.001). Using receiver operating characteristic (ROC) curves, a free prostate specific antigen of 13% was the best cutoff value for predicting prostate cancer. CONCLUSIONS: In subjects with prostate specific values between 4 and 10 ng/ml, the measurement of the free fraction of this antigen can improve the predictive value of this parameter for the detection of prostate cancer.

[Laparoscopic adrenalectomy. Initial results of a Chilean experience]. / Adrenalectomía laparoscópica. Resultados de una experiencia chilena inicial.

BACKGROUND: Laparoscopic adrenal approach was introduced in 1992 and is becoming the surgical method of choice for several adrenal diseases. AIM: To report the initial Chilean experience in laparoscopic adrenalectomy. MATERIAL AND METHODS: A retrospective review of 17 patients subjected to the surgical procedure by the authors. RESULTS: The preoperative diagnosis were adenomas (8 patients), pheochromocytoma (3), cystic lesions (2), adrenal metastases (2), hyperaldosteronism (1) and a pituitary Cushing (1). The average lesion size was 5.4 cm, the operative time 2.5 hours and the hospital stay 2.5 days. Eight patients were discharged in less than 48 hours. Pain was managed with non steroidal antiinflammatory drugs in 14 patients. One subject required conversion to open surgery. Transfusions were required in complex cases with a diaphragmatic hamartoma, Cushing disease and in a combined adrenal and renal resection. One patient had to be re admitted due to a pancreatic pseudo cyst that was drained percutaneously. There have been no recurrences after a mean follow up of 2 years. CONCLUSIONS: This early experience with laparoscopic adrenalectomy shows good results. A good patient selection and experience with advanced laparoscopic surgery are requisites for a successful use of this surgical technique.

[Hemorrhagic tuberous sclerosis. Report of a Jehovah Witness patient]. / Esclerosis tuberosa sangrante. Caso clínico en un paciente Testigo de Jehová.

We report a 26 years old male with a tuberous sclerosis with multiple and bilateral kidney cysts and angiomyolipomas. The patient presented to the emergency room with a severe abdominal pain and anemia, secondary to a bleeding angiomyolipoma. The patient rejected blood transfusions due to his religious beliefs. A selective angiography was performed confirming diagnosis and the lesion artery was selectively embolized, stopping the bleeding immediately. The patient had a satisfactory evolution thereafter. This is a rare lesion and the fact that the patient was a Jehovah witness that rejected blood transfusions, required an innovative medical approach.

[Neodymium YAG laser in treating prostatic adenoma]. / Láser de neodimio YAG en el tratamiento del adenoma de próstata.

BACKGROUND: Conventional surgery and transurethral ablation are the treatments of choice for benign prostatic hyperplasia. AIM: To report our experience with Neodynium: YAG laser ablation of prostatic adenomas. PATIENTS AND METHODS: Revision of 182 patients subjected to Laser ablation of benign prostatic adenoma of whom 28 had a complete urinary retention and 50 were considered of high surgical risk. RESULTS: One hundred eighty patients had spontaneous voiding after surgery, there were no intraoperatory complications and were discharged 6 to 24 hours after the procedure. Urinary flow increased from 8 ml/sec in the preoperative period to 20 and 21 ml/sec, two and six months after surgery. Symptom score decreased from 12 to 1.2 points. Seven patients had late hematuria and two required vesical lavage and cystoscopic clot drainage. Ten patients had a positive urine culture. 12 had lack of ejaculation and 75%, had some degree of dysuria. CONCLUSIONS: Neodynium YAG laser ablation of benign prostatic adenoma seems to be efficient and safe.

[Treatment of priapism with phenylephrine]. / Tratamiento del priapismo mediante fenilefrina.

Pathological erection may be ascribed to different causes and its treatment represents a challenge to the attending urologist. For the past 3 years we have utilized intracavernous phenylephrine to treat this condition. Our success rate is 93.1%, with detumescence achieved between 30 sec to 15 min. No complications have been observed and the responders have referred no changes in their sexual activity. We therefore advocate its use before recurring to more aggressive maneuvers.

[Microwave transurethral thermotherapy in the treatment of prostatic adenoma]. / Termoterapia transuretral, por microondas en el tratamiento del adenoma de próstata.

We report 195 patients with prostatic adenoma treated with microwave transurethral thermotherapy. All patients were initially subjected to a clinical assessment including Madsen-Iversen symptom score, digital rectal examination, measurement of urine flow rate and residual urine volume, transrectal prostatic ultrasound examination and blood prostate specific antigen determination. A prostatron machine was used, installing an urethral probe under local anesthesia. Endourethral and rectal temperatures were simultaneously measured and the procedure was controlled by a special software. The treatment was performed in an outpatient basis with a single procedures that lasted 60 min. Of 31 patients with chronic urinary retention, 28 were left voiding spontaneously, without urethral catheters and 84% of 164 symptomatic patients were relieved. No complications occurred, although 31.1% of patients has a transitory urinary retention after the procedure. It is concluded that microwave thermotherapy is a good therapeutic alternative for prostatic adenoma.

[Laparoscopic lumboaortic retroperitoneal lymphadenectomy in testicular neoplasm]. / Linfadenectomía retroperitoneal lumboaórtica laparoscópica en cáncer de testículo.

Lumboaortic lymphadenectomy is a therapeutic alternative for patients with nonseminomatous testis tumors and its principal untoward effect is the loss of ejaculation. The anatomic knowledge of lymph node metastasis allows lower limit definition of aortic dissection, maintaining the diagnostic sensitivity and ejaculation. We report three patients with nonseminomatous testis tumors subjected to a reduced video-laparoscopic lumboaortic lymphadenectomy. An adequate amount of tissue was obtained in all and lymph node metastasis found in two. No complications occurred and patients were discharged 48 hours later. It is concluded that this technique is an alternative staging technique with low morbidity that allows a rapid patient discharge.

[Experience with the use of stomach in bladder reconstruction]. / Experiencia con el uso de estomago en reconstrucción vesical.

Bladder reconstruction with a gastric portion, as an alternative to other intestinal segments, has gained popularity lately. We have used a vascularized gastric segment for bladder replacement in 20 patients aged 3 to 77 years old, between 1990 and 1993. The surgical indication was due to a severe radiation cystitis in 11 cases, neurogenic bladder in 4, urinary diversion in 4 and cystectomy due to bladder cancer in 2. In 18 cases, associated surgical procedures were performed. Mild complications occurred in 3 cases and no patient died. Postoperative evolution has been excellent. Sixteen patients maintained a normal miction and 4 required self performed urethral intubation. It is concluded that stomach is a good alternative for bladder reconstruction. We are employing it with higher frequency in our practice due to the technical simplicity and the physiological advantages of its use. The metabolic acidosis secondary to ionic absorption that occurs with the use of other intestinal segments, specially in patients with renal failure, is avoided. Also, it facilitates surgical procedures in patients with severe abdominal radiation damage.

[Laparoscopic nephrectomy: report of 2 cases]. / Nefrectomia laparoscópica: comunicación de 2 casos.

Laparoscopic surgery has become very popular in general surgery. Its most significant advantages for patients are a better postoperative comfort and fast return to work. We report two young female patients with a gynecologic cancer in whom a laparoscopic nephrectomy was performed. The surgical procedure and the post operative recovery were uneventful. These promising results show that laparoscopic surgery is applicable in traditional urologic procedures.

[Extracorporeal lithotripsy by shock waves: results in 185 patients]. / Litotricia extracorpórea mediante ondas de choque: resultados en 185 pacientes.

Extracorporeal shock wave lithotripsy has become the treatment of choice of nephrolithiasis with surgical indication. Our unit is managing urinary tract stones using the Sonolith 3000 lithotritor since April 1991. The procedure is performed in ambulatory patients and requires analgesia and mild sedation. We report the experience in the treatment of the first 185 patients. In 87% of them, the stones disappeared completely, 8.7% of patients were left with residual fragments without indication of further treatments and in 4.3% the procedure failed. There was no mortality. In 13 occasions, obstructive complications at the distal ureter were produced by the stone fragments that required ureteroscopy in only three patients and 11 patients had severe renal colic. We conclude that this procedure is safe and effective in the treatment of urinary tract stones.

Transurethral microwave thermotherapy for the treatment of benign prostatic hyperplasia: preliminary experience.

One hundred and fifty patients with symptomatic benign prostatic hypertrophy (BPH) underwent transurethral microwave thermotherapy (TUMT). The single 1-hour TUMT session in the clinic was well tolerated and without significant adverse events. The mean Madsen urinary symptom score declined from 11.3 to 2.1 with a concomitant 54% increase in peak urinary flow rates by 4 months. Of the 22 patients with catheter-dependent urinary retention, 91% became catheter free. These early results appear to establish TUMT as an effective treatment of symptomatic BPH.

Analgesia y sedación endovenosa para litotripsia extracorpórea / Endovenous analgesia and sedation for extracorporeal lithotripsy

Los autores analizan el procedimiento anestésico empleado en 100 procedimientos consecutivos de litotripsia extracorpórea utlizando el Sonolith 3000. Se aplicó un protocolo prospectivo de sedación y analgesia con Midazolam y Fentanila, en 92 pacientes, 61 hombres y 31 mujeres, con una edad promedio de 41 años. Se obtuvo analgesia satisfactoria en el 94 por ciento de los casos, siendo el tiempo necesario para obtener analgesia de 10 minutos. El período de recuperación postanestésica fue de 50 minutos en promedio. Las complicaciones fueron mínimas. La técnica de sedación y analgesia con Midazolam y Fentanila es simple de realizar, con rápido inicio de acción, exenta de complicaciones significativas y con una rápida recuperación

[Transurethral thermotherapy in prostatic adenoma]. / Termoterapia transuretral en el adenoma prostático.

Microwave thermotherapy is considered to be an alternative to conventional surgical treatment of benign prostatic hyperplasia (BPH). Our initial experience of the first six months shows this technique has achieved objective improvement of the symptoms and uroflowmetry, as well as a significant reduction of postmicturition residual urine. It carries a minimal morbidity, no mortality and has permitted recovery of micturition in over 90% of the patients with urinary retention.

[Current diagnosis of renal cancer: clinical experience with 71 cases]. / Diagnóstico actual del cáncer renal: experiencia clínica en 71 casos.

The diagnosis of renal cell carcinoma was frequently delayed due to the anatomic location of kidneys. Recently, the development of echographic imaging techniques has drastically changed this situation. In this retrospective review of 71 patients with renal cell carcinoma, the diagnosis was made incidentally during a routine abdominal ultrasound examination in 49% of cases. These patients, has lower stage and smaller tumors than symptomatic patients. Among the latter, hematuria was the principal presenting symptom. The early diagnosis of renal cell carcinoma allows more conservative surgical procedures and has a favorable effect on long term survival.

[Renal oncocytoma: 4 cases]. / Oncocitoma renal: cuatro casos.

Oncocytomas are tumors characterized by cells with an eosinophilic cytoplasm. Renal oncocytomas were described in 1942. Among 46 consecutive patients operated on for renal tumors, oncocytomas were found in 4 (8.7%). In spite of a supposedly benign nature, renal oncocytoma cannot be adequately differentiated from renal adenocarcinoma by imaging techniques. Therefore, we recommend radical surgery as the treatment of choice in these patients.