[Hand-assisted laparoscopic nephrectomy]. / Nefrectomia laparoscópica mano-asistida.

INTRODUCTION AND OBJECTIVES: To present the number of cases of hand-assisted laparoscopic nephrectomy. This study evaluates our results and difficulties of starting a progresive programme of laparoscopy. MATERIAL AND METHOD: Between november 2003 and november 2005, 35 hand-assisted laparoscopic nephrectomies were carried out, of a total of 45 laparoscopic nephrectomies. 22 radical nephrectomies, 3 simple nephrectomies and 10 nephroureterectomies. The average age of patients was 66 years (47-89). On average, they were overweight (IMC 28,3), with approximately 38% being obese. ASA 2.3 (1-4). The tumors measured 4.8cm on average, and 80% of these were T1. In 28.6% of the cases, they had previously undergone abdominal surgery. RESULTS: One was undertaken in 2003, 17 in 2004, and 17 in 2005. The surgery time was 140 minutes, 130 minutes (80-210) in radical nephrectomies, 135 minutes (120-150) in simple nephrectomies and 163 minutes (80-240) in the nephroureterectomy. Patients began an oral diet 1.7 days later, and were able to get up 1.7 days later. In the case of obese patients, they began an oral diet 2.3 days later and were able to get up (2.4 days) later than those non obese cases. (1.5 and 1.4 days respectively). The average stay has been 5.8 days (3-15). The average stay of the cases without complications was 4.2 days and those that encountered complications 9.7 days. In no cases was there a need for a blood transfusion. In 11.4% we had major complications with an average stay of 11.7 days. In 5.7% of cases there were reconversions, and 5.7% of cases were reoperated. 17.1% had minor complications, with an average stay of 8.8 days CONCLUSIONS: The advantage of hand-assisted nephrectomy is that it allows one to begin a laparoscopy, with a reduced learning time, and with satisfactory results, allowing the incorporation of laparoscopy surgery in hospitals with a reduced annual volume.

Nefrectomía laparoscópica mano-asistida / Hand-assisted laparoscopic nephrectomy

Introducción y Objetivos: Presentamos nuestra casuística de nefrectomías laparoscópicas mano-asistidas. Se valoran nuestros resultados y las dificultades del inicio de un programa progresivo de laparoscopia. Material: Desde noviembre 2003 hasta noviembre 2005 se han realizado 35 nefrectomías laparoscópicas Mano-asistidas, de un total de 45 nefrectomías laparoscópicas. 22 nefrectomías radicales, 3 nefrectomías simples y 10 nefroureterectomías. Media de edad 66 años (47-89). Tenían una media de sobrepeso (IMC 28,3); 38% eran obesos. ASA 2,3 (1-4). Los tumores tenían 4,8 cm de tamaño medio; 80% eran T1. El 28,6% habían sido operados previamente de cirugía abdominal. Resultados: Se realizaron 1 en 2003, 17 en 2004, y 17 en 2005. El tiempo quirúrgico ha sido 140 minutos, 130 minutos (80-210) en nefrectomías radicales, 135 minutos (120-150) en nefrectomías simples y 163 minutos (80-240) en nefroureterectomías. Los pacientes iniciaron dieta oral en 1,7 días y se levantaron en 1,7 días. Los obesos iniciaron la dieta (2,3 días) y se levantaron (2,4 días) más tarde que los no obesos (1,5 y 1,4 días respectivamente). La estancia media ha sido 5,8 días (3-15); en los no complicados 4,2 días y en los que han tenido complicaciones 9,7 días. En ningún caso se trasfundió. Hemos tenido 11,4% de complicaciones mayores con EM de 11,7 días. Un 5,7% de reconversiones y 5,7% de reoperaciones. Y 17,1% de complicaciones menores, con EM de 8,8 días. Conclusiones: La nefrectomía mano-asistida es una técnica que por sus ventajas permite un inicio en la laparoscopia, con menor curva de aprendizaje, y resultados satisfactorios, permitiendo incorporar la cirugía laparoscópica a hospitales con un menor volumen anual

Introduction and objectives: To present the number of cases of hand-assisted laparoscopic nephrectomy. This study evaluates our results and difficulties of starting a progresive programme of laparoscopy. Material and Method: Between november 2003 and november 2005, 35 hand-assisted laparoscopic nephrectomies were carried out, of a total of 45 laparoscopic nephrectomies. 22 radical nephrectomies, 3 simple nephrectomies and 10 nephroureterectomies. The average age of patients was 66 years (47-89). On average, they were overweight (IMC 28,3), with approximately 38% being obese. ASA 2.3 (1-4). The tumors measured 4.8cm on average, and 80% of these were T1. In 28.6% of the cases, they had previously undergone abdominal surgery. Results: One was undertaken in 2003, 17 in 2004, and 17 in 2005. The surgery time was 140 minutes, 130 minutes (80-210) in radical nephrectomies, 135 minutes (120-150) in simple nephrectomies and 163 minutes (80-240) in the nephroureterectomy. Patients began an oral diet 1.7 days later, and were able to get up 1.7 days later. In the case of obese patients, they began an oral diet 2.3 days later and were able to get up (2.4 days) later than those non obese cases. (1.5 and 1.4 days respectively). The average stay has been 5.8 days (3-15). The average stay of the cases without complications was 4.2 days and those that encountered complications 9.7 days. In no cases was there a need for a blood transfusion. In 11.4% we had major complications with an average stay of 11.7 days. In 5.7% of cases there were reconversions, and 5.7% of cases were reoperated. 17.1% had minor complications, with an average stay of 8.8 days Conclusions: The advantage of hand-assisted nephrectomy is that it allows one to begín a laparoscopy, with a reduced learning time, and with satisfactory results, allowing the incorporation of laparoscopy surgery in hospitals with a reduced annual volume

[Bilateral germ tumors of the testis. Report of 5 cases and review of the literature]. / Tumores germinales bilaterales de testículo. Aportación de cinco casos y revisión de la literatura.

OBJECTIVE: To know the prevalence of the bilateral germ cell tumours of testis diagnosed in our Department and to review the literature. MATERIAL AND METHODS: 64 patients diagnosed of a germ cell tumour of the testis were followed during an average period of 51.4 months (1-168 months). RESULTS: 5 (7.8%) patients developed a second germ cell testicular tumour. In one patient the tumours were synchronous while in the remaining four were metachronous, occurring in an average interval of 59 months. One patient with a metachronous tumour died as consequence of the second tumour. In two of the five patients risk factors were identified, one presented testicular atrophy and the second referred history of undescended testis. DISCUSSION: The probability of developing a germinal testis tumour between the patients with history of a previous germ cell tumour of the testis is sensibly greater than between the general population. The prevalence of the bilateral tumours of the testis oscillates between 1-5% and approximately 75% will be metachronous. The principal factor that can predict the appearance of a second testicular tumour is the presence of the carcinoma in situ (Cis) in the contralateral testicular biopsy. Except in cases of testicular atrophy or previous history of undescended testis we do not recommend routine biopsy of the other testis.

[Self-administration of an oil solution in the penis]. / Autoinoculación de una solución oleosa en el pene.

We report the case of a patient who has autoinjected himself the penis and the scrotum with a solution constituted by petroleum, vaseline, oxygenated water and ketoconazol gel. Treatment consists in the excision of the injected deposit of lipid material and antibiotic therapy with good result at 4 months. We review the existing literature related with this exceptional pathology.

[Anuria in HIV+ patients treated with indinavir]. / Anuria en pacientes HIV+ tratados con Indinavir.

OBJECTIVE: Two cases of oliguric acute renal failure in HIV+ patients treated with indinavir are described. METHODS: Patient evaluation included blood analysis, urinalysis, abdominal x-rays, renal US and IVP. RESULTS: Both cases resolved with discontinuation of drug therapy, administration of fluids and urine acidification. CONCLUSIONS: Severe acute renal failure is an uncommon complication in HIV+ patients treated with indinavir. This drug has a great tendency to precipitate in urine. The severity of the crystalluria depends on the drug dose and urinary pH, and can cause tubulointerstitial nephritis and urinary calculi with obstruction of the urinary tract.

Tumores germinales bilaterales de testículo. Aportación de cinco casos y revisión de la literatura / Bilateral germ cell tumors of the testis. Report of five cases and review of the literature

OBJETIVO: Conocer la prevalencia de los tumores germinales bilaterales de testículo diagnosticados en nuestro Servicio y revisar la literatura. MATERIAL Y MÉTODOS: 64 pacientes diagnosticados de un tumor germinal de testículo (TGT) fueron seguidos ambulatoriamente durante un periodo medio de 51,4 meses (1-168 meses).RESULTADOS: 5 (7,8 por ciento) pacientes tuvieron un segundo TGT. En un paciente los tumores fueron sincrónicos mientras que en los cuatro restantes fueron metacrónicos, apareciendo en un periodo medio de 59 meses. De los cuatro pacientes con tumores metacrónicos uno falleció como consecuencia del segundo tumor. En dos de los cinco pacientes identificamos la existencia factores predisponentes, uno presentaba historia de atrofia testicular secundaria a una orquitis urliana y el segundo refería historia de criptorquidia. DISCUSIÓN: La probabilidad de desarrollar un tumor germinal de testículo entre los pacientes con historia de un tumor germinal previo es sensiblemente mayor que entre la población general. La prevalencia de los tumores bilaterales de testículo oscila entre el 1-5 por ciento. Un 75 por ciento serán metacrónicos. El principal factor que puede predecir la aparición de un segundo tumor testicular es la presencia del carcinoma in situ (Cis) en la biopsia de la gónada contralateral. Salvo en casos de atrofia y/o antecedentes de criptorquidia en el testículo contralateral no aconsejamos la biopsia rutinaria de la gónada contralateral (AU)

Autoinoculación de una solución oleosa en el pene / Self-inoculation of an oily solution in the penis

Presentamos el caso de un paciente que se autoinyectó en el pene y en escroto una solución constituida por petróleo, vaselina, agua oxigenada y gel de ketoconazol. Se trató con desbridamiento y antibioticoterapia con buen resultado a los 4 meses. Revisamos la literatura existente en relación a esta excepcional patología (AU)

[Cystic nephroma. Report of 5 cases]. / Nefroma quístico. A propósito de 5 casos.

OBJECTIVE: To report 5 cases of cystic nephroma and review the clinical, diagnostic and therapeutic aspects. METHODS: From 1974 to 1988, 5 cases of cystic nephroma were diagnosed at our hospital. Patient evaluation included IVP and renal US, and occasionally ascending urography, fine needle aspiration biopsy and CT. The cyst was removed through a lumbar incision in 4 patients and nephrectomy in one patient. RESULTS: The patients were followed by yearly ultrasound/urography for 1 to 15 years. No evidence of local recurrence or metastatic disease has been found. CONCLUSIONS: Cystic nephroma is an uncommon, benign kidney disease whose etiology is unknown. Although new imaging techniques are available, surgical excision and histologic analysis of the tumor are the only effective methods to distinguish benign from malignant cystic lesions of the kidney. Because it is a benign lesion, surgery must be conservative. Complete excision of the cyst is advocated. We found a well-encapsulated, noninfiltrating lesion that permitted surgical excision without difficulty in most of our cases. Herniation of some cysts into the urinary tract is a characteristic radiological sign.

[Foreign body as renal pseudotumor in a patient with renal polycystic kidney]. / Cuerpo extraño como pseudotumor renal en un paciente con poliquistosis renal.

OBJECTIVE: To report a case of granuloma due to a retained surgical sponge that mimicked a pseudotumor in a patient with autosomal dominant polycystic kidney disease. The appearance of retained surgical sponges on diagnostic imaging is reviewed. METHODS: Patient evaluation included renal ultrasound, magnetic resonance imaging (MRI) and arteriography. RESULTS: MRI provides characteristic features that permit preoperative diagnosis. CONCLUSIONS: In the presence of a mass or abscess in patients who have previously undergone surgery, a retained surgical sponge should be included in the differential diagnosis. MRI permits preoperative diagnosis.

[Etiopathogenesis and management of paraneoplastic fever and Stauffer syndrome in renal carcinoma]. / Etiopatogenia y manejo de la fiebre paraneoplásica y del síndrome de Stauffer en el carcinoma renal.

Some paraneoplastic syndromes as fever, cachexia, loss of weight or hepatic dysfunction, are relatively frequent in patients affected by a renal cell carcinoma (RCC). However their pathogeny has been unknown until a short time ago. The advances in immunology have permitted to identify the interleukin-6 as the responsible for these changes. In spite of our better knowledge, the treatment of these paraneoplastic syndromes, when persist after the removal of the tumor, continues being a challenge. We present the case of a patient with a renal cell carcinoma that began as a feverish syndrome, developing thereinafter a hepatic dysfunction or Stauffer's syndrome. The paraneoplastic symptoms persisted after removal of the tumor. No response to the administered treatment has been observed. The patient died two months after the surgery.

[Upper urinary tract tumors: results of treatment and follow-up]. / Tumores del tracto urinario superior: resultados del tratamiento y seguimiento.

OBJECTIVE: To present the results of treatment and follow-up of 105 patients with tumor of the upper urinary tract. METHODS: A retrospective study was conducted on 105 patients (88 male and 17 female; mean age 68.3 years) with tumor of the upper urinary tract that had been treated from 1975 to 1997. In total 114 functional units were treated, including recurrences and bilateral tumors. The sites of involvement were: ureter (49.9%), pelvis (41.2%) and the entire upper urinary tract (8.7%). Ninety-six percent were transitional cell carcinomas: 4.8% were well differentiated (GI), 68% moderately differentiated (G2) and 26.8% poorly differentiated (G3); 58.6% were superficial, while 41.3% showed tumor invasion into or beyond the muscle layer. Ninety-two of the 105 patients were followed. The SPSS program was employed for the statistical analysis. The survival was calculated by the Kaplan-Meier method and the differences by the log rank test. Multivariance analysis was performed using the Cox regression method. TREATMENT: 58% underwent radical nephroureterectomy, 30% were treated conservatively and 11.6% underwent partial resection of the upper urinary tract. Recurrence: 8.7% of the patients showed tumor recurrence. The recurrence rate after conservative surgery was 13.6% and was as high as 80% in the remaining ureter. Metastasis: 22.8% of the patients presented metastasis to the retroperitoneal lymph nodes, bone, liver and lungs. Survival: In the univariate analysis tumor stage, age, radical and conservative surgery were found to influence survival, while stage and surgery (radical or conservative) were found to be statistically important by multivariate analysis. CONCLUSIONS: The treatment of choice for high grade and stage transitional cell carcinoma is by radical surgery, whereas for the superficial and well differentiated tumors, conservative management can achieve similar survival rates while preserving the renal unit and upper urinary tract.

[Renal leiomyosarcoma. Apropos a case]. / Leiomiosarcoma renal. A propósito de un caso.

OBJECTIVE: To describe an additional case of leiomyosarcoma of the kidney in a patient that presented with nonspecific abdominal pain and a palpable mass. The clinical features, diagnosis and therapeutic aspects, as well as the prognostic factors of this tumor type are reviewed. METHODS: Patient evaluation included US, CT and MRI. The patient underwent a left radical nephrectomy and received adjuvant external radiotherapy. RESULTS: The patient is asymptomatic and has no local recurrence or metastasis 15 months postoperatively. CONCLUSIONS: Leiomyosarcoma of the kidney is an uncommon malignant mesenchymal tumor. To our knowledge, less than 100 cases have been reported in the literature. Its clinical features and the US, CT and MRI findings are not unlike those of renal adenocarcinoma. The treatment of choice is by radical nephrectomy.

[Expression of protein p53 in superficial transitional carcinoma of the bladder with differing course]. / Expresión de la proteína p53 en carcinomas transicionales vesicales superficiales con distinta evolución.

OBJECTIVE: To determine the prognostic value of p53 protein expression in relation to progression of superficial bladder cancer. METHODS: A retrospective study was conducted in which p53 protein was determined in TUR fragments of 18 patients with superficial transitional cell carcinoma of the bladder with no evidence of tumor progression in the last 6 years and in 13 patients with superficial tumors that had become invasive. DO-7 monoclonal antibody was utilized (+if stained nuclei were more than 25%). RESULTS: Expression of p53 protein was found in 9 patients (50%) with bladder tumors that had not progressed and in 6 patients (46.1%) with bladder tumors that had become invasive (p = 0.83). CONCLUSION: Determination of p53 protein was not related with cancer progression in this series.

[Leiomyosarcoma of the inferior vena cava. Apropos of a case]. / Leiomiosarcoma de cava inferior. A propósito de un caso.

Presentation of one case of inferior cava leiomyosarcoma in a 24-year old female patient, incidentally diagnosed after performance of ultrasound. The complementary examinations performed (CAT, NMR, arteriography) guided to a mass of suprarenal origin. During surgery, a tumour of the inferior cava vein was suspected and was later confirmed through the pathoanatomical study of the surgical piece. Review of the clinical and diagnostic aspects placing special emphasis on treatment.

[Rectorrhage as an unusual extrarenal complication after ESWL]. / Rectorragias como complicación extrarrenal poco habitual tras LEOC.

We report a case of rectorrhage due to an hematoma of sigmoid colon post ESWL in a patient with chronic hepatopathy and right ureteral calculus. We comment the clinic and endoscopical study, as well as the review of literature.

[Immunotherapeutic treatment for metastatic renal carcinoma]. / Tratamiento inmunoterápico para el carcinoma renal metastásico.

Immunotherapy management for advanced renal carcinoma has awaken a growing interest over the last few years. Based on Atzpodien's studies, in December 1994 a protocol was initiated in our centre for the treatment of metastatic renal carcinoma, using subcutaneous alpha interferon, subcutaneous Interleukin-2 and endovenous 5-Fluorouracil. The present report analyzes all six cases included in the protocol and their results.

[Tumors of the upper urinary tract: epidemiology, clinical, and diagnosis]. / Tumores del tracto urinario superior: epidemiología, clínica y diagnóstico.

OBJECTIVE: To review the epidemiological, clinical and diagnostic aspects of upper urinary tract tumors (UUTT). METHODS: The clinical records of 105 patients with UUTT were reviewed. There were 114 functioning units in total. Data on distribution according to sex, age at presentation, involved side, focality, localization, association with bladder tumor, risk factors, clinical features, radiological and histological findings were analyzed. Descriptive statistical analysis was performed and the means and frequency rates were estimated. RESULTS: Of the 105 patients, 88 (83.8%) were male and 17 (16.1%) were female, accounting for a male to female ratio of 5.1:1. The mean age was 68.3 +/- 10.5 years (range 24-88). The tumor involved the left side in 52 cases (49.5%), the right side in 49 cases (46.6%) and 4 cases (3.8%) had bilateral involvement; 84 (80%) were unifocal and 21 (20%) were multifocal. The pyelocaliceal region was compromised in 41.2% (47/114) of the functioning units, the lumbar ureter in 14% (16/114), the sacral ureter in 7% (8/114), the pelvic ureter in 28.9% (33/114) and the entire upper urinary tract in 8.7% (10/114). UUTT was associated with a bladder tumor in 60.9%. The bladder tumor and UUTT presented simultaneously in 26 cases (29.8%). The bladder tumor presented before the UUTT in 35 cases (40.2%) and in 26 cases (29.8%) it presented after. Smoking was found to be the most important risk factor. Hematuria was the most common reason for consultation (67.6%), followed by flank pain (23.8%), and 13.3% were asymptomatic. The most common urographic finding was a filling defect (46.4%), followed by loss of function (36.8%) and hydronephrosis (20.1%). Loss of renal function was observed in 66% of the cases with metastasis. Histologically, 99% were transitional cell carcinoma, basically moderately differentiated (68.8% grade II) and non infiltrating (58.6% pTa-pT1). CONCLUSIONS: Our findings are largely in agreement with the data published in the literature, although we have found a very high incidence of UUTT associated with bladder tumor in our series.

[Prostatic rhabdomyosarcoma in adults]. / El rabdomiosarcoma de próstata en el adulto.

OBJECTIVE: To report on two adult patients with prostatic embryonal rhabdomyosarcoma. The literature is briefly reviewed and the clinical, diagnostic and therapeutic aspects of this unusual variety of prostate cancer are discussed. METHODS: Two patients, aged 27 and 34 years, with prostatic embryonal rhabdomyosarcoma are presented. Both cases showed tumor dissemination at the time of diagnosis. Both patients received chemotherapy. RESULTS: A 60% reduction in tumor volume was achieved in one patient, who subsequently underwent rescue surgery and, in spite of a recurrence, is still alive 3 years after the diagnosis. The other patient showed no response to chemotherapy. He refused rescue surgery and was lost to follow-up. CONCLUSION: Embryonal rhabdomyosarcoma of the prostate in the adult is an unusual and aggressive tumor, of rapid growth and progression. Early diagnosis and treatment without delay by radical surgery and chemotherapy are essential to improve the prognosis of this disease.