Early complications of endoscopic treatment for superficial bladder tumors.

PURPOSE: Bladder tumors are the second most common tumors of the genitourinary system. Approximately 80% of patients initially present with a superficial lesion, which is treated with transurethral resection. Although transurethral resection is a standard procedure, it is not morbidity-free. We assessed the early complications of transurethral resection for superficial bladder cancer and analyzed various factors that may contribute to its occurrence. MATERIALS AND METHODS: Between January 1979 and December 1996, 2,821 patients with superficial bladder cancer underwent transurethral resection at our center. We assessed intraoperative and immediate postoperative complications of the initial transurethral resection procedure, and correlated them with tumor characteristics. RESULTS: Of the 2,821 patients in our study 2,461 (87%) were male and 360 (13%) were female. Average age was 65 years (range 16 to 94). Of the 145 complications (5.1%) the most common were bleeding in 78 patients (2.8%) and bladder perforation in 36 (1. 3%). Perforation was extraperitoneal in 30 cases (83%) and intraperitoneal in 6 (17%). Conservative treatment and open surgery were done in 32 (89%) and 4 (11%) patients, respectively. We noted no case of tumor seeding. A repeat procedure was done in 77 patients (2.7%) with bleeding as the leading cause of repeat intervention in 65 (84%). Blood transfusion was required in 96 cases (3.4%). The incidence of complications significantly correlated with the size and number of tumors but there was no association with tumor stage, grade or location. CONCLUSIONS: The most common complication of transurethral resection for superficial bladder cancer is bleeding. Currently bladder perforation should be managed conservatively with a minimum risk of extravesical tumor seeding. Our results imply that tumor size and multiple tumor resection are associated with a higher complication rate.

Propuesta de nuevo protocolo en los tumores vesicales superficiales: ¿por qué? / A new protocol in the management of superficial bladder tumours: why?

Grandes grupos internacionales como M.R.C. y EORTC preconizan protocolos estrictos: cistoscopia cada tres meses el primer año, cada seis vieses en el segundo año y una anual per vitam Autores de reconocido prestigio, recomiendan siete o diez cistoscopias durante los tres primeros años de seguimiento. Algunos proponen interrumpido al año o cinco años y otros prefieren practicar controles endoscópicos indefinidamente (AU)

Study of allelic losses on 3p, 6q, and 17p in human urothelial cancer.

Forty-eight transitional cell carcinomas of the bladder and three transitional cell carcinomas of the renal pelvis were examined for loss of heterozygosity (LOH) on chromosomes 3p, 6q, and 17p. The most frequent allelic loss was seen on 17p (18/36, 50%) followed by 6q (6/22, 27%), and 3p (5/22, 23%). In cases with LOH at more than one locus, the same DNA sample often varied in degree of signal reduction for missing alleles. This observation indicates that LOH studies can serve to detect intratumor heterogeneity. No correlation was found between allelic losses at these chromosome arms and tumor grade and stage. Allelic losses on 6q were associated with tumors having a solid growth pattern; in this kind of tumors, allelic losses on 3p were associated with invasion.

Restriction fragment length polymorphism of the L-myc gene is not a prognostic factor in bladder cancer patients.

The L-myc restriction fragment length polymorphism has been suggested to be of prognostic significance in some types of primary tumours. We examined the prognostic and susceptibility significance of the L-myc genotype in a group of 98 bladder cancer patients. The L-myc genotype did not correlate with any pathologic parameter and does not offer any clinical utility in patients with bladder cancer.

Analysis of 3p allelic losses in renal cell carcinomas: comparison with cytogenetic results.

We performed a study of loss of heterozygosity (LOH) at 3p by restriction fragment length polymorphism analysis in a series of 22 renal tumors. In 11 cases, molecular results could be compared with those of cytogenetic studies. The highest frequency of allelic losses at 3p was seen in clear cell non-papillary renal tumors, whereas none of the papillary renal cell carcinomas showed LOH at 3p. Allelic losses on 3p were found to be independent of tumor grade or stage or both. One case analyzed showed a discrepancy between cytogenetic and LOH studies. This tumor displayed rearrangements of chromosome 3 and no LOH at the c-RAF-1 (close to the Von Hippel Lindau gene) locus.

[Squamous cell carcinoma of the penis: treatment protocol according to our 14 years of experience]. / Carcinoma escamoso de pene; protocolo de tratamiento según nuestra experiencia en 14 años.

OBJECTIVE: The management of lymph nodes and the determination of prognostic factors are matters of controversy in the treatment of squamous cell carcinoma of the penis. We attempted to establish an approach based on the different types of lymphadenectomies and biopsies we have performed and to evaluate local stage and grade of cellular differentiation as prognostic factors. METHODS: 81 cases treated at our institution between 1980 and 1994 were reviewed. The results of the different lymphadenectomies and biopsies performed were analyzed. Tumors were staged according to the Jackson and TNM classifications; in 62 cases the pathological samples were reexamined by the same pathologist to determine the grade of cellular differentiation according to the Broders classification. A p value of < 0.05 was considered significant. RESULTS: We did not obtain reliable results with the biopsies done and variable results in the lymphadenectomies performed. The grade of cellular differentiation and local stage were both statistically significant with respect to the presence of positive lymph nodes. We found statistically significant differences for survival according to the stage of the positive lymph nodes. CONCLUSION: We have established three approaches in management of squamous cell carcinoma of the penis according to the local stage and grade of cellular differentiation.

Grade, local stage and growth pattern as prognostic factors in carcinoma of the penis.

OBJECTIVES: To assess the management of adenopathies and the determination of prognostic factors in the treatment of squamous carcinoma of the penis. MATERIALS AND METHODS: We reviewed 81 cases treated at our Institution between 1980 and 1994. In 62 cases, we review the pathologic samples according to the growth patterns proposed by Cubilla et al. RESULTS: We find that both the grade of cellular differentiation and the local stage of the tumor are statistically significant with respect to the presence of positive adenopathies. We obtain results similar to Cubilla's work and different survival rates for the patterns of tumor growth. CONCLUSIONS: On the basis of our results, we propose 3 differentiated follow-up and treatment groups. We suggest that the new growth pattern classification is useful as prognostic factor in carcinoma of the penis. We corroborate that prophylactic lymphadenectomy is indicated in tumors of vertical growth, while a conservative management should be considered in tumors of verrucous growth.

[Low incidence of mutations in codon 12 of the c-K-ras gene in bladder cancer]. / Baja incidencia de mutación del codon 12 del gen c-K-ras en el cáncer vesical.

During vesical carcinogenesis a variety of genetic alterations such as oncogene mutation or loss of suppressor genes have been detected. Codon 12 mutation of the c-K-ras gene has been seen with a high frequency in several human neoplasias but its participation in the development of vesical cancers has not been fully dilucidated. Using the DNA restriction fragments polymorphism (RFLP) technique enhanced by a polymerase chain reaction (PCR) a study has been made of codon 12 mutation at the c-K-ras gene in 55 patient with vesical cancer undergoing surgery between 1991 and 1992. The tumoral stage was superficial (Ta-Tl) in 24 cases, infiltrant (T2-T4) in 28 cases and unknown in 3 cases. Two patients (3.6%) showed codon 12 mutation at the c-K-ras gene. One case was a fast evolving infiltrant tumour (T2-T3) which caused death of the patient after 4 months while the other case was a surface tumour (G2Ta) which relapsed early, the pathological anatomy revealing a stage T2-T3 squamous carcinoma. Our results suggest that codon 12 mutation at the c-K-ras gene is not a meaningful genetic change in the genesis of vesical cancer. Its emergence, however, appears to be related to a more aggressive tumoural behaviour.

[The IPPS questionnaire in patients and controls. Psychometric validation]. / Cuestionario IPSS en pacientes y controles. Validación psicométrica.

The translation into Spanish of the AUA/International Prostatic Symptom (AUA/IPS) Score hadn't been validated in spanish. METHODS. AUA/IPS questionnaire was self administered by 103 consecutive patients and by 24 healthy volunteers. An alternative formulation to question 4 (ALT-4) was added. RESULTS. 51 patients (49%) and 17 controls (79%) completed al questions (Feasibility). Reliability was measured by: a) Crohnbach's alpha (0.68 and 0.70 with ALT-4) b) Kendall's coefficient of concordance (0.097, significance < 0.001) and c) retesting 17 patients within 2 months. The relation of the AUA/IPS scores with quality of life (Construct validity) showed a Spearman's correlation coefficient of 0.57 (confidence = 0.0001), and 0.52/0.0004 with ALT-4. The relation with uroflowmetry (Concurrent empirical validity) was poor as shown in ROC curves. CONCLUSIONS. The Spanish version of the AUA/IPS questionnaire given in an easy format improves feasibility without alteration of reliability or validity. The relation of the AUA/IPS score with uroflowmetry is poor, although the questionnaire can be considered valid and reliable.

Preoperatively recognized chronically retained pararenal gauzoma.

A granuloma caused by a forgotten laparotomy gauze (gauzoma) was suspected in a patient with general symptoms, a well-defined pararenal mass on computed tomography and a history of retroperitoneal surgery, and was subsequently confirmed at surgery. The image diagnosis of retained surgical sponges is briefly reviewed.

Renal abscess due to Aspergillus fumigatus in a patient with the acquired immunodeficiency syndrome.

Disseminated aspergillosis is a systemic fungal infection that may occur in previously healthy or immunocompromised patients. The condition, although rare, is being recognized with increasing frequency in persons with the human immunodeficiency virus. Clinical genitourinary involvement is unusual. We present a case of renal abscess for Aspergillus fumigatus in a patient with acquired immunodeficiency syndrome who complained of flank pain and fever.

[Open surgery of calculus of the kidney pelvis. Results and complications in the era of extracorporeal lithotripsy]. / Chirurgie á ciel ouvert de la lithiase du bassinet. Résultats et complications dans l'ére de la lithotripsie extracorporelle.

From 1989 to 1993, 11,535 extracorporeal shock wave lithotripsy (ESWL) sessions were performed in 6,066 patients in our centre. In contrast, simple or extended pyelolithotomy was the treatment of choice in a small group of patients. The object of this paper is to review the results and complications of this type of operation. A total of 57 pyelolithotomies was performed, including 33 extended pyelolithotomies, in 55 patients (26 men and 29 women). The mean age of the series was 50 years (range: 5-77). The operated kidney was the left kidney in 34 cases and the right kidney in 23 cases. The mean interval between the diagnosis and the operation was 31 months. 64% of the patients had history of stone disease (33 ipsilateral and 2 bilateral). Thirteen patients had already been treated by ESWL (10 patients), percutaneous nephrolithotomy (PNL) (2 cases) and one case had previously undergone pyelolithotomy. A urinary tract infection was observed in 26 patients (47%). The incision consisted of lumbotomy in 40 patients (71%), or a subcostal incision in 12 cases. The mean operating time was 161 minutes (range: 90-245) and the mean intraoperative bleeding was 500 ml. Thirteen patients were transfused (23%). The renal artery had to be clamped in 9 cases (for an average of 19 minutes). After a mean follow-up of 20 month, 50.8% of patients were stone-free. 49% of patients presented residual caliceal fragments on the immediate postoperative X-ray. One patient had to be treated by percutaneous nephrolithotomy and ESWL. 12 cases (41% of patients with residual fragments) required subsequent treatment by ESWL and the remaining patients with residual fragments were asymptomatic and did not receive any further treatment. The immediate postoperative complication rate was 17% and 10% of patients developed late postoperative complications. Simple or extended pyelolithotomy remains an effective treatment for stones of the renal pelvis, either on its own or associated with ESWL. However, the possibility of serious complications demands meticulous patient selection.

[Bladder neck sclerosis after transurethral resection of the prostate. "Study Group of the Puigvert Foundation"]. / Esclerosis de cuello vesical tras resección transuretral de próstata. "Grupo de Estudio de la de la Fundación Puigvert".

We reviewed 623 patients who underwent trans-urethral resection of the prostate (TURP) and 18 (2.8%) developed bladder neck contracture (BNC), in most cases symptomatic. Sclerosis appeared between 2 and 100 months after TURP (mean 9 months, median 19 months). Most were small prostates at the time of resection, with a mean resected weight of 10.5 g (SD 5.9), although there were no statistically significant differences between patients with and without contracture. Patients have been followed for a mean of 44.5 months. Three patients were not operated: two were asymptomatic and another one died one month postoperatively due to unrelated causes. The overall success rate was 75% and cold knife incision of the bladder neck accounted for a 90% success rate. Cold knife incision provides good long term satisfaction in patients with post-operative BNC. The difficulties in the study of this complication are analyzed.

[Clinical course in patients with BPH operated for acute urine retention]. / Evolución de los pacientes con HBP operados por retención aguda de orina.

Between 1980 and 1990, 5,949 cases of Benign Prostate Hyperplasia (BPH) were detected at the Puigvert Foundation. One thousand of them were randomized for analysis, and it was found that in 347 the indication for surgery was acute urine retention (AUR). During the initial visit the symptoms, their duration, creatinine values, correlation between creatinine and: 1) patients over 70 years, 2) relationship to prostate size, 3) distention of the upper urinary tract, 4) vesical lithiasis, 5) urinary infection, 6) complications, and 7) mortality were analyzed. Discussion of results, comparing these to other series and trying to find evolution differences between these patients and those operated by elective surgery. In our series, we only found statistically significant differences when correlating the high values of creatinine with the prostate size and the upper urinary tract distension.

[Cytogenetic characteristics and of primary culture in multiple renal tumors]. / Características citogenéticas y de cultivo primario en tumores renales múltiples.

The incidence of multiple tumours in renal cancer ranges between 1 and 30%. In these cases, it becomes very difficult to differentiate between adenoma and carcinoma just by using conventional methods, particularly in borderline cases. We carried out primary cultures and subsequent cytogenetic studies in 2 patients with multiple renal cancer. Clonal numerical changes in the first case were: 3, 7, 16 and 17 trisomies, chromosome loss; and structural changes, del(1) (p34), del(2) (p16, p22). In the second case, clonal numerical changes were 7 trisomy and tetrasomy and loss of the Y chromosome. Both tumours were cytogenetically characterized as papillary renal tumours. The diagnostic approaches are discussed and the prognosis possibilities evaluated, using this method to evaluate them in multiple renal tumours.

[The urologist's language: a survey on symptoms]. / El lenguaje de los urólogos: una encuesta sobre síntomas.

The definition of urologic symptoms varies depending on the source. Some symptoms are particularly vague and their clinical usefulness is doubtful. A survey was sent to 500 spanish urologists, asking about terminology and normality limits. There were 17 items, most of them as multiple choice questions, and all of them with the possibility of an open answer. The response rate, two months after the mailing was 12% (60 physicians). The variability of the answers was high for most of the items. In most questions over half of the respondents (between 50 and 70%, depending on the question) agreed, whereas the rest gave different answers. The free answers given were also different. This discrepancy affected all of the questions. The low response rate can be attributed to the scare tradition of this kind of survey in our country. The disparity in the definitions urges a unification of them, or at least that authors explain what they understand when they mention any symptom or syndrome.

Antimicrobial prophylaxis in urologic surgery: does it give some benefit?

Three types of antibiotic prophylactic regimens were evaluated versus a control without prophylaxis (group A: 3,912 cases) in urologic surgery. The antibiotic regimens were: group B = cefazolin 1 g/12 h/3 days (3,660 cases); group C = cefonicid 1 g/24 h/3 days (2,076 cases), and group D = cefonicid 1 g single dose (3,169 cases). The parameters used were the comparison of the corresponding rates of postsurgical sepsis and operative wound infections. Numeric investigations for the validity of a retrospective study (unpaired data) were performed: homogenicity test, relative risk point estimate and confidence limits (95%), and etiological fraction point estimate and confidence limits (95%). Chi-square for other purposes were performed. Endoscopic handling was considered homogeneous (same infective risk), while open surgery was heterogeneous (p < 0.001). In order to avoid probable bias, a correction factor was used. Although in different degrees, prophylaxis significantly reduced the morbidity of surgical wound infections (p < 0.001; etiological fraction > 90%). The differences (p < 0.01) between groups B and C/D were attributed to pharmacokinetic causes (short T 1/2 of cefazolin). To obtain the maximum protective effect, the use of antibiotics with a T 1/2 of > 4 h is suggested. There was no resistant mutans in previously sensitive strains. However, a significant selection of intrinsically resistant strains was observed. Monodose offers at lest the same advantages as multiple-dose therapy. In addition, the monodose selected in a lesser proportion both the resistant strains (p < 0.001) and the number of microbial associations (p < 0.01).

Functional equivalence of end and loop ileal conduit stomas.

A total of 458 patients underwent ileal conduit urinary diversion between 1970 and 1984. An end stoma was constructed in 44% of the patients and a Turnbull loop stoma in 56%. The median interval between appliance changes for all patients was 5 days. Patients with an end stoma had a longer median interval between appliance changes than those with a loop stoma. A total of 51 patients had 66 complications. Operations for stomal revisions were required in 5.5% of the patients. There was no difference in interval until initial complication between the end and loop stoma groups, although the end stoma was more prone to ischemic complications than the loop stoma. We conclude that the ileal conduit stoma constructed in an end or loop fashion yielded clinically equivalent long-term function.

Carcinoma in situ as a prognostic factor for G3pT1 bladder tumours.

G3pT1 bladder cancer has traditionally been regarded as a superficial tumour with a high risk of progression. We have studied 37 patients with initial G3pT1 bladder tumours treated between January 1981 and December 1985. They were divided into 2 groups according to the association with carcinoma in situ (Cis) at the time of diagnosis. Clinical behaviour was analysed at 5 years. The first group (without Cis) showed progression and recurrence rates similar to those of low grade, low stage bladder tumours. The second group (with Cis) had a similar rate of recurrence but their progression rate was 65%.