Down Syndrome-Basque Alzheimer Initiative (DS-BAI): Clinic-Biological Cohort.

BACKGROUND: Down syndrome (DS) is the most common genetically determined intellectual disability. In recent decades, it has experienced an exponential increase in life expectancy, leading to a rise in age-related diseases, including Alzheimer's disease (AD). Specific health plans for the comprehensive care of the DS community are an unmet need, which is crucial for the early and accurate diagnosis of main medical comorbidities. We present the protocol of a newly created clinical and research cohort and its feasibility in real life. METHODS: The Down Syndrome-Basque Alzheimer Initiative (DS-BAI) is a population-based, inclusive, multidisciplinary initiative for the clinical-assistance and clinical-biological research approach to aging in DS led by the CITA-Alzheimer Foundation (Donostia, Basque Country). It aims to achieve the following: (1) provide comprehensive care for adults with DS, (2) optimize access to rigorous and quality training for socio-family and healthcare references, and (3) create a valuable multimodal clinical-biological research platform. RESULTS: During the first year, 114 adults with DS joined the initiative, with 36% of them showing symptoms indicative of AD. Furthermore, adherence to training programs for healthcare professionals and families has been high, and the willingness to collaborate in basic and translational research has been encouraging. CONCLUSION: Specific health plans for DS and conducting clinical and translational research on the challenges of aging, including AD, are necessary and feasible.

Cryoablation and Immunotherapy: An Enthralling Synergy for Cancer Treatment.

As less invasive options for surgical tumor removal, minimally invasive ablative techniques have gained popularity. Several solid tumors are being treated with cryoablation, a non-heat-based ablation technique. Cryoablation data in comparison over time demonstrates better tumor response and faster recovery. Combining cryosurgery with other cancer therapies has been explored to improve the cancer-killing process. Cryoablation with the combination of immunotherapy, results in a robust and efficient attack on the cancer cells. This article focuses on investigating the ability of cryosurgery to create a strong antitumor response when combined with immunologic agents resulting in a synergetic effect. To achieve this objective, we combined cryosurgery with immunotherapy using Nivolumab and lpilimumab. Five clinical cases of lymph node, lung cancer, bone, and lung metastasis were followed and analyzed. In this series of patients, percutaneous cryoablation and addressing immunity agents were technically feasible. In the follow-ups, there appeared to be no radiological evidence of new tumor development.

Evaluation of the predictive value of the hematopoietic progenitor cell count using an automated hematology analyzer for CD34+ stem cell mobilization and apheresis product yield.

INTRODUCTION: We evaluated the value of hematopoietic progenitor cells (HPCs) counted in Sysmex XN analyzers to predict the mobilization and collection of CD34+ cells in apheresis for stem cell transplantation. METHODS: Eighty patients who underwent stem cell transplantation were enrolled (50 autologous and 30 allogeneic). In the autologous group, patients were considered poor mobilizers when the CD34+ count was <10 × 106 /L or <20 × 106 /L in patients with multiple myeloma who were going to undergo two transplants. ROC curves were generated, and HPC cutoffs were calculated. RESULTS: The correlation between the HPC and CD34+ cell counts was good. Two algorithms were proposed. In the first algorithm, samples collected the day before apheresis, negative and positive HPC cutoffs were selected to detect poor and good mobilization and, therefore, the need or not to administer plerixafor. In the second algorithm, samples collected pre-apheresis, the negative HPC cutoff was an indication to delay apheresis; an HPC higher than the optimal cutoff was an indication to start apheresis. When the HPC values were between these cutoffs, there was an indication to count CD34+ cells for a better decision-making. Finally, in samples collected pre-apheresis, HPC counts could be used to predict patients who would have poor CD34+ cell collections. In the allogeneic group, all the donors mobilized well, and very few needed two apheresis procedures. CONCLUSIONS: The HPC count is useful for decision-making in the management of patients subjected to apheresis procedures to collect peripheral blood stem cells.

Cryoelectrolysis; an acute case study in the pig liver.

We report results from an acute, single case study in the pig liver on the effects of a tissue ablation protocol (we named cryoelectrolysis) in which 10 min of cryosurgery, with a commercial cryosurgical probe, are delivered after 10 min of electrolysis generated by a current of about 60 mA. The histological appearance of tissue treated with cryoelectrolysis is compared with the appearance of tissue treated with 10 min of cryosurgery alone and with 10 min of electrolysis alone. Histology done after 3 h survival shows that the mixed rim of live and dead cells found around the ablated lesion in both cryosurgery and electrolytic ablation is replaced by a sharp margin between life and dead cells in cryoelectrolysis. The appearance of the dead cells in each, cryoelectrolysis, cryosurgery and electrolytic ablation is different. Obviously, this is an acute study and the results are only relevant to the conditions of this study. There is no doubt that additional acute and chronic studies are needed to strengthen and expand the findings of this study.

[Palpable undescended testicle: Surgical treatment by pre-scrotal incision Bianchi's Technique]. / Testículo no descendido palpable. Tratamiento quirúrgico mediante incisión para-escrotal: "Técnica de Bianchi".

OBJECTIVE: To present a retrospective, descriptive and observational study performed on a group of patients diagnosed with palpable undescended testicle (PUT) and surgically treated by pre-scrotal access, the "Bianchi technique". METHODS: The sample consists of a group of patients from 6 to 168 months old, diagnosed with palpable undescended testicle and treated by orchidopexy through pre-scrotal access Bianchi type (4), from January 2008 to June 2015 by the Pediatric Urology Equipment of Malaga, where the authors belong. To be part of the sample, the patients must meet the following requirements: male, diagnosis PUT, older than 6 months old and a minimum of 6 months of postoperative follow. RESULTS: The sample is comprised of 200 testicles and 157 patients diagnosed with PUT, aged between 6 and 168 months old and treated by the same main surgeons. In a 72.62% of the patients the anomaly was unilateral. From the 200 testicles intervened, a 51.5% had PUT on the right side. Localization of the undescended testis was in the inguinal canal in a 64.5% of cases, 22.5% in the superficial inguinal canal and a 13% in the deep one. There weren't significant complications but in 4.5% of the cases there were minor complications that did not require treatment (cutaneous scrotal hematoma, 2.5%; scrotal skin edema, 1.5%, and partial dehiscence, 0.5%). Regarding the state of the scar, in 15.5% it's not visible, in 16% excellent, very good in 12.5% and only 1% had a bit of an hypertrophic aspect. CONCLUSIONS: This is a easy technique, which presents good surgical results, with minimum surgical complications, its short, medium and long term results are excellent and with a great aesthetic appearence.

Testículo no descendido palpable. Tratamiento quirúrgico mediante incisión para-escrotal: 'Técnica de Bianchi' / Palpable undescended testicle: Surgical treatment by pre-scrotal incision Bianchi's Technique

OBJETIVO: Es presentar un estudio retrospectivo, descriptivo y observacional realizado sobre un grupo de pacientes diagnosticados de testículo no descendido palpable (TNDP) y tratados quirúrgicamente mediante la incisión para-escrotal, técnica 'Bianchi'. MÉTODOS: La muestra está formada por un grupo de pacientes de entre 6 y 168 meses de edad, diagnosticados de testículo no descendido palpable y tratados mediante orquidopexia a través de incisión para-escrotal tipo Bianchi (4), desde enero de 2008 a junio de 2015 por el Equipo de Urología Pediátrica de Málaga, al que los autores pertenecen. Para formar parte de la muestra los pacientes debían de cumplir los siguientes criterios: sexo masculino, diagnóstico de TNDP, edad mayor de 6 meses y tiempo mínimo de seguimiento postoperatorio de 6 meses. RESULTADOS: La muestra la componen 200 testículos y 157 pacientes diagnosticados de TNDP, con edades comprendidas entre los 6 y 168 meses y tratados por los mismos cirujanos principales. En un 72,62% de los pacientes la anomalía fue unilateral. De los 200 testículos intervenidos, un 51,5% presentaba el TNDP en el lado derecho. Localizándose el teste no descendido en un 64,5% de los casos en el conducto inguinal, un 22,5% en el conducto inguinal superficial y un 13% en el profundo. No hubo complicaciones significativas si bien se registraron un 4,5% de complicaciones leves que no requirieron tratamiento (hematoma cutáneo escrotal, 2,5%; edema cutáneo escrotal, 1,5% y dehiscencia cutánea parcial, 0,5%). Con respecto al estado de la cicatriz, en un 15,5% no se visualizaba, 16% excelente, muy bien 12,5% y sólo en 1% presentaron un aspecto algo hipertrófico. CONCLUSIONES: Es una técnica de sencilla ejecución y fácilmente reproducible, que presenta buenos resultados, mínimas complicaciones quirúrgicas. Sus resultados a medio y largo plazo son excelentes y con magnífico aspecto estético

OBJECTIVE: To present a retrospective, descriptive and observational study performed on a group of patients diagnosed with palpable undescended testicle (PUT) and surgically treated by pre-scrotal access, the 'Bianchi technique'. METHODS: The sample consists of a group of patients from 6 to 168 months old, diagnosed with palpable undescended testicle and treated by orchidopexy through pre-scrotal access Bianchi type (4), from January 2008 to June 2015 by the Pediatric Urology Equipment of Malaga, where the authors belong. To be part of the sample, the patients must meet the following requirements: male, diagnosis PUT, older than 6 months old and a minimum of 6 months of postoperative follow. RESULTS: The sample is comprised of 200 testicles and 157 patients diagnosed with PUT, aged between 6 and 168 months old and treated by the same main surgeons. In a 72.62% of the patients the anomaly was unilateral. From the 200 testicles intervened, a 51.5% had PUT on the right side. Localization of the undescended testis was in the inguinal canal in a 64.5% of cases, 22.5% in the superficial inguinal canal and a 13% in the deep one. There weren't significant complications but in 4.5% of the cases there were minor complications that did not require treatment (cutaneous scrotal hematoma, 2.5%; scrotal skin edema, 1.5%, and partial dehiscence, 0.5%). Regarding the state of the scar, in 15.5% it's not visible, in 16% excellent, very good in 12.5% and only 1% had a bit of an hypertrophic aspect. CONCLUSIONS: This is a easy technique, which presents good surgical results, with minimum surgical complications, its short, medium and long term results are excellent and with a great aesthetic appearance

Measurement of liver iron concentration by MRI is reproducible.

PURPOSE: The objectives were (i) construction of a phantom to reproduce the behavior of iron overload in the liver by MRI and (ii) assessment of the variability of a previously validated method to quantify liver iron concentration between different MRI devices using the phantom and patients. MATERIALS AND METHODS: A phantom reproducing the liver/muscle ratios of two patients with intermediate and high iron overload. Nine patients with different levels of iron overload were studied in 4 multivendor devices and 8 of them were studied twice in the machine where the model was developed. The phantom was analysed in the same equipment and 14 times in the reference machine. RESULTS: FeCl3 solutions containing 0.3, 0.5, 0.6, and 1.2 mg Fe/mL were chosen to generate the phantom. The average of the intramachine variability for patients was 10% and for the intermachines 8%. For the phantom the intramachine coefficient of variation was always below 0.1 and the average of intermachine variability was 10% for moderate and 5% for high iron overload. CONCLUSION: The phantom reproduces the behavior of patients with moderate or high iron overload. The proposed method of calculating liver iron concentration is reproducible in several different 1.5 T systems.

Transperineal laparoscopy: a new approach.

PURPOSE: We describe and evaluate a new transperineal laparoscopic approach for male patients, designed to facilitate laparoscopic prostatectomy and cystectomy. PATIENTS AND METHODS: We operated on 12 patients. We did three laparoscopic prostatectomies and nine laparoscopic cystectomies. On five, an ileal conduit was made, and on the other four, an orthotopic bladder was constructed. An incision was made in the perineum. A space was bluntly created between the rectum and the prostate. A cannula was then introduced up to the Douglas pouch, which was opened to enter the peritoneal cavity. RESULTS: One patient of the three prostatectomies needed incontinence pads. None of the four orthotopic bladder cases presented daytime incontinence. The urethra of one of the patients who had an ileal conduit was injured. No other significant complications occurred. CONCLUSION: Transperineal laparoscopy in male patients is a feasible technique that may be an alternative for natural orifice translumenal endoscopic surgery in women, but further assessment is required.

[Multi-instruments cannula: a new concept of laparoscopy]. / Cánula multi-instrumentos: un nuevo concepto de laparoscopia.

OBJECTIVES: Five or six perforations of the abdominal wall increase the possibilities of organ injury, infection, or hernia. Laparoscopy originally offered great advantages and significant progress. Multiple abdominal ports are now considered superfluous, excessively traumatic and, today, hardly merit the term 'minimally-invasive-surgery'. All that led us to design a device to help surgeons meet new standards that can have several uses. METHODS: The instrument is a 4 cm diameter, 5 cm long cannula. The superior extremity or lid has five 5 mm sealed openings, one for the telescope and four for instruments. Below the lid and its notched retaining screw is the tap to insufflate the operating field. The peripheral flange limits insertion depth and seals the skin wound. Lids with more or less openings are available. The device has been proven first in a simulator, and then five pigs between 20 and 30 kg have been operated. In the first two cases the cannula was introduced through the umbilicus and a cystostomy with suture was carried out. In the other three cases nephrectomy was performed inserting the cannula through the flank. RESULT The experimental series has allowed us to get adapted to the cannula; we have verified that diameter and length of the device are optimal, and vision is excellent. Also the device is hermetic, since there is no loss of gas and the instruments are not trapped inside, what has allowed us to work and to suture without special difficulty. DISCUSSION: A single port through the abdomen or even transvaginally represent a real challenge to laparoscopy because in the 21st century to make 5 or 6 perforations in the abdominal wall appear untenable. Finally, with this system there are enormous possibilities for robotization with only one arm that includes the telescope and instruments, that sooner that we might imagine is going to revolutionize surgical practice.

Cánula multi-intrumentos: un nuevo concepto de laparoscopia / Multi-instruments cannula: a new concept of laparoscopy

Objetivo: Cada vez resulta más obvio que 5 ó 6 punciones abdominales suponen un grave riesgo de lesión de una viscera, infección, hernia, dolor, además del efecto estético y que eso a estas alturas dista mucho de ser considerado un procedimiento mínimamente invasivo. Porque lo que en el siglo pasado, hace 20 años, eran grandes ventajas, hoy pueden ser serios inconvenientes. Por ello urge buscar alternativas menos cruentas y más acordes con los tiempos que corren. Todo eso nos ha llevado a diseñar un dispositivo, que creemos puede tener numerosas aplicaciones. Métodos: El instrumento consiste en esencia en una cánula de 4 centímetros de diámetro y 5 de profundidad. El extremo superior, a modo de tapadera, tiene 5 orificios de 5 milímetros, por donde van la óptica y otros 4 a su alrededor por donde van los diversos instrumentos. A un lado hay una llave de paso para el gas. Esta tapa es intercambiable, en caso necesario, por otra con dos orificios de 5 mm y otro de 12. El dispositivo se ha probado primero en un simulador y a continuación se han operado cinco cerdos de entre 20 y 30 kilos. En los dos primeros se introdujo la cánula por el hipogastrio y se realizó una cistostomía con sutura y en los otros tres se practicó una nefrectomía poniendo la cánula en el flanco. Resultado: La serie experimental nos ha permitido adaptarnos a la cánula, hemos comprobado que el diámetro y la longitud de la misma son adecuados y que la visión es excelente. Asimismo el dispositivo es hermético, ya que no hay pérdida de gas y los instrumentos no quedan atrapados, lo que nos ha permitido trabajar y suturar sin dificultad. Discusión: Estamos convencidos de que un trocar único vía abdominal o incluso transvaginal supone un auténtico desafío a la laparoscopia convencional, ya que en el Siglo XXI realizar seis perforaciones en el vientre del paciente empieza a ser insostenible. Por último, con este sistema hay enormes posibilidades para la robotización con un único brazo que incluya óptica e instrumentos, que muy probablemente, antes de que lo imaginemos, va a revolucionar la práctica quirúrgica (AU)

Objectives: Five or six perforations of the abdominal wall increase the possibilities of organ injury, infection, or hernia. Laparoscopy originally offered great advantages and significant progress. Multiple abdominal ports are now considered superfluous, excessively traumatic and, today, hardly merit the term 'minimally-invasive-surgery'. All that led us to design a device to help surgeons meet new standards that can have several uses. Methods: The instrument is a 4 cm diameter, 5 cm long cannula. The superior extremity or lid has five 5 mm sealed openings, one for the telescope and four for instruments. Below the lid and its notched retaining screw is the tap to insufflate the operating field. The peripheral flange limits insertion depth and seals the skin wound. Lids with more or less openings are available. The device has been proven first in a simulator, and then five pigs between 20 and 30 kg have been operated. In the first two cases the cannula was introduced through the umbilicus and a cystostomy with suture was carried out. In the other three cases nephrectomy was performed inserting the cannula through the flank. Result: The experimental series has allowed us to get adapted to the cannula; we have verified that diameter and length of the device are optimal, and vision is excellent. Also the device is hermetic, since there is no loss of gas and the instruments are not trapped inside, what has allowed us to work and to suture without special difficulty. Discusion: A single port through the abdomen or even transvaginally represent a real challenge to laparoscopy because in the 21st century to make 5 or 6 perforations in the abdominal wall appear untenable. Finally, with this system there are enormous possibilities for robotization with only one arm that includes the telescope and instruments, that sooner that we might imagine is going to revolutionize surgical practice (AU)

[Gunshot wound with a bullet lodged in the prostate]. / Bala alojada en la próstata.

OBJECTIVE: We describe a most unusual urological emergency: a firearm wound in which the blunt-nosed hand-gun bullet was lodged in the prostate. A bibliographic search of the literature revealed no similar case. METHODS: The patient was admitted presenting a gunshot wound with the entrance hole on the right buttock. There was no exit wound. An X-ray revealed the bullet behind the pubic symphysis. We introduced a suprapubic catheter and then carried out a laparotomy making a discharge colostomy Urethrogram revealed a pathway of contrast to the rectum. Several days later, we reached the bladder with an urethrotome and introduced an 18 Fr catheter. Under radiological control we made an open approach to the retropubic space, palpated the bullet within the prostate and then removed it. DISCUSSION/CONCLUSIONS: The velocity of a rifle or hand-gun bullet is the main determinant of the severity of this type of injury. As there was no exit wound, we knew that the entrance velocity was low, therefore tissue damage would probably be small. In these cases, a preparatory suprapubic cystostomy is essential to be able to carry out a urethral reconstruction later. Radiological control during the procedure proved extremely useful to precisely locate the bullet. Our conservative approach of simply leaving in place the catheter helped us later to avoid a difficult repair of a recto-urethral fistula.

Bala alojada en la próstata / Gunshot wound with a bullet lodged in the prostate

Objetivo: Describimos un caso de herida de arma de fuego con el proyectil alojado en la próstata. La rareza de este tipo de heridas en nuestro medio, así como el hecho de no haber encontrado ningún caso similar en la literatura nos han animado a escribir este artículo. Métodos: Se trata de un paciente que nos llega con una herida de bala con orificio de entrada por la nalga y sin orificio de salida. En el estudio radiológico se encuentra una bala situada detrás de la sínfisis del pubis. En principio se pone un catéter suprapúbico, se hace una laparotomía y se realiza una colostomía de descarga. Después se realiza una uretrografía y se comprueba que hay paso de contraste hacia el recto. Unos días más tarde, mediante un uretrotomo, se llega hasta la vejiga y se deja una sonda del número 18 Fr. A continuación, vía abierta se llega al espacio retropúbico, mediante control radiológico se identifica la bala, después se consigue palparla alojada dentro de la próstata y por último se extrae. Discusión/Conclusiones: Es muy importante conocer la velocidad del proyectil para saber la gravedad de la lesión. En este caso, al no haber orificio de salida, sabemos que el proyectil es de baja velocidad, lo que hace que la gravedad del traumatismo sea mucho menor. La cistostomía suprapúbica inicial es imprescindible en estos casos para luego hacer en un segundo tiempo la reconstrucción uretral. El control radiológico durante la intervención es muy útil para localizar el proyectil. En este caso se demuestra que teniendo una actitud conservadora, dejando simplemente una sonda evitamos una cirugía difícil como puede ser la reparación de una fístula recto-uretral (AU)

Objective: We describe a most unusual urological emergency: a firearm wound in which the blunt-nosed hand-gun bullet was lodged in the prostate. A bibliographic search of the literature revealed no similar case. Methods: The patient was admitted presenting a gunshot wound with the entrance hole on the right buttock. There was no exit wound. An X-ray revealed the bullet behind the pubic symphysis. We introduced a suprapubic catheter and then carried out a laparotomy making a discharge colostomy. Urethrogram revealed a pathway of contrast to the rectum. Several days later, we reached the bladder with an urethrotome and introduced an 18 Fr catheter. Under radiological control we made an open approach to the retropubic space, palpated the bullet within the prostate and then removed it. Discussion/Conclusions: The velocity of a rifle or hand-gun bullet is the main determinant of the severity of this type of injury. As there was no exit wound, we knew that the entrance velocity was low, therefore tissue damage would probably be small. In these cases, a preparatory suprapubic cystostomy is essential to be able to carry out a urethral reconstruction later. Radiological control during the procedure proved extremely useful to precisely locate the bullet. Our conservative approach of simply leaving in place the catheter helped us later to avoid a difficult repair of a recto-urethral fistula (AU)

[Evaluation of parathyroid function in presternal subcutaneous grafting after total parathyroidectomy for renal hyperparathyroidism]. / Evaluación de la función paratiroidea en el injerto subcutáneo preesternal tras paratiroidectomía total en el hiperparatiroidismo renal.

INTRODUCTION: In the setting of total parathyroidectomy (TPT) and parathyroid transplantation (PTx) for renal hyperparathyroidism (RHP), we evaluated long-term parathyroid graft function after subcutaneous presternal transplantation (SCPTx). HYPOTHESIS: Parathyroid glands are surrounded by fatty tissue. Therefore, we postulated that subcutaneous implantation of parathyroid tissue after TPT for RHP could be at least as effective as intramuscular grafting and would avoid the complications of the latter technique. MATERIAL AND METHOD: We performed a study in a university hospital and its dialysis unit. DESIGN: Prospective open efficacy study of a postoperative diagnostic monitoring method of intact parathyroid hormone (iPTH) in a cohort of surgical patients without loss to follow-up. PATIENTS AND INTERVENTIONS: Thirty-five patients (19 women and 16 men) underwent TPT and SCPTx for RHP at the Department of General Surgery and Department of Nephrology, Donostia Hospital, San Sebastián, Gipuzkoa, Spain, from January 2002 to December 2005. Follow-up ranged from 6 to 42 months (mean, 15.4 months). Graft function was evaluated by measurement of plasma iPTH levels before surgery and 24 hours and 1, 3, 5, 15, 30, 60, 100 and 150 weeks after surgery. Reference values for PTH in our laboratory were 20-65 pg/mL. RESULTS: The mean preoperative iPTH values were 1245 +/- 367.9 pg/mL (mean +/- SD) (range, 493-2160). After TPT and SCPTx, iPTH levels became undetectable in all patients at 24 hours. A value of 50 pg/mL was established as the criterion for adequate parathyroid graft function. The following values were obtained: 15.54 +/- 10.61 pg/mL (mean +/- SD) (range, 6-44) after 1 week, 57.2 +/- 1.9 pg/mL (mean +/- SD) (range, 43-74) after 5 weeks, 64.21 +/- 9.73 pg/mL (mean +/- SD) (range, 11.3-89) after 15 weeks, 75.12 +/- 9.05 pg/mL (mean +/- SD) (range, 24.6-104.2) after 30 weeks, 101.63 +/- 19.85 pg/mL (mean +/- SD) (range, 65-143) after 60 weeks, 121.63 +/- 27.85 pg/mL (mean +/- SD) (range, 62-179) after 100 weeks, 63 +/- 19.85 pg/mL (mean +/- SD) (range, 68-723) after 150 weeks and 102 +/- 18.65 pg/mL (mean +/- SD) (range, 68-113) after 200 weeks. The prevalence of hypoparathyroidism (serum iPTH level of < 20 pg/mL with a normal or low serum calcium concentration) was 2 out of 35 patients (5.71%) by week 60, with recovery of normal values by week 100. Graft-related recurrence occurred in one out of 35 patients (2.85%). CONCLUSIONS: SCPTx after TPT and PTx for secondary RHP is an adequate method to replace muscular forearm parathyroid transplantation and avoid its complications. The functional results of TPT and SCPTx compare favorably with published data on other surgical techniques proposed for the treatment of RHP. Long-term follow-up of this series is currently being performed.

[Subcutaneous endoscopic surgery in urology]. / Cirugía endoscópica subcutánea en urología.

OBJECTIVES: In endoscopic subcutaneous surgical procedures, new to Urology, the subcutaneous tissues are insufflated with carbon dioxide through a trocar to create working space without a surgical incision. Although this technique now predominates in surgery of the face, neck and breast, from the literature it appears that it has not yet been adopted for surgery in the region of the inguinal canal or in the scrotum. We describe these approaches. METHODS: To carry out the inguinal canal approach we introduced three 5mm trocars and dissected the external oblique fascia until we identified the superficial inguinal ring and gained access to the scrotum. The scrotal approach is directly into the scrotum. To date, we have only used the scrotal approach to treat hydroceles. We carefully detached the tunica vaginalis from the scrotal wall and kept the tunica intact before puncturing it to empty the fluid contents. The tunica was then resected and withdrawn through a trocar. RESULTS: We have removed three cysts and one solid tumor of the spermatic cord with the inguinal approach. With the scrotal approach we have treated six hydroceles. Our experience with these two small series allows us to confidently state that the procedure offers no particular technical difficulty; that operating times are short and that post-operative pain is very probably less than usual. CONCLUSIONS: Although endoscopic subcutaneous surgery in Urology is in its infancy, our results until now have been excellent and permit us to conclude that in the future there will be more indications for this type of surgery.

Evaluación de la función paratiroidea en el injerto subcutáneo preesternal tras paratiroidectomía total en el hiperparatiroidismo renal / Evaluation of parathyroid function in presternal subcutaneous grafting after total parathyroidectomy for renal hyperparathyroidism

Introducción. En el contexto de la paratiroidectomía total (TPT) y trasplante paratiroideo (PTx) para el hiperparatiroidismo renal (RHP) evaluamos la función a largo plazo de injerto paratiroideo después de trasplante subcutáneo preesternal (SCPTx). Hipótesis: las glándulas paratiroideas están rodeadas por tejido adiposo. Por lo tanto, postulamos que la implantación subcutánea después de paratiroidectomía en el hiperparatiroidismo renal puede ser al menos tan eficaz como el implante muscular y sin sus complicaciones evolutivas. Material y método. Estudio realizado en un hospital universitario y su unidad de diálisis. Diseño: estudio prospectivo sobre la eficacia del procedimiento mediante determinación de paratirina intacta (iPTH) en una cohorte de pacientes quirúrgicos sin pérdida en el seguimiento. Pacientes e intervenciones: 35 (19 mujeres y 16 varones) fueron sometidos a TPT y SCPTx por RHP en el Departamento de Cirugía y Servicio de Nefrología, Hospital de Donostia (San Sebastián, Gipuzkoa, España), entre enero de 2002 y diciembre de 2005. El seguimiento ha variado entre 6 y 42 (media, 15,4) meses. Se evaluó la función del injerto mediante la determinación de las concentraciones plasmáticas de iPTH antes de la operación y 24 horas y 1, 3, 5, 15, 30, 60, 100, 150 y 200 semanas después. Los valores de referencia para la PTH en nuestro laboratorio fueron de 20-65 pg/ml. Resultados. Los valores medios preoperatorios ± desviación estándar de iPTH fueron de 1.245 ± 367,9 (rango, 493-2.160) pg/ml. Después de la TPT y el SCPTx, las concentraciones de iPTH llegaron a ser indetectables en todos los casos a las 24 horas. Se estableció 50 pg/ml como criterio de función adecuada de injerto paratiroideo. Los valores obtenidos fueron: 15,54 ± 10,61 (rango, 6-44) pg/ml a la semana, 57,2 ± 1,9 (rango, 43-74) pg/ml a las 5 semanas, 64,21 ± 9,73 (rango, 11,3-89) pg/ml a las 15 semanas, 75,12 ± 9,05 (rango, 24,6-104,2) pg/ml a las 30 semanas, 101,63 ± 19,85 (rango, 65-143) pg/ml a las 60 semanas, 121,63 ± 27,85 (rango, 62-179) pg/ml a las 100 semanas, 63 ± 19,85 (rango, 68-723) pg/ml a las 150 semanas y 102 ± 18,65 (rango, 68-113) pg/ml a las 200 semanas. La frecuencia de hipoparatiroidismo (concentración de iPTH en suero < 20 pg/ml con una concentración normal o baja de calcio en suero) fue 2/35 (5,71%) a la semana 60, y se recuperó para la semana 100. La recidiva relacionada con el injerto fue del 2,85% (1/35). Conclusiones. El trasplante subcutáneo preesternal tras paratiroidectomía total y trasplante paratiroideo para el hiperparatiroidismo renal secundario parece un método adecuado como alternativa al trasplante muscular antebraquial y para evitar sus complicaciones. Los resultados funcionales del injerto se comparan favorablemente con los datos publicados sobre otras técnicas quirúrgicas utilizadas para el tratamiento del hiperparatiroidismo renal. El seguimiento a largo plazo de la serie está en curso (AU)

Introduction. In the setting total of parathyroidectomy (TPT) and parathyroid transplantation (PTx) for renal hyperparathyroidism (RHP), we evaluated long-term parathyroid graft function after subcutaneous presternal transplantation (SCPTx). Hypothesis: Parathyroid glands are surrounded by fatty tissue. Therefore, we postulated that subcutaneous implantation of parathyroid tissue after TPT for RHP could be at least as effective as intramuscular grafting and would avoid the complications of the latter technique. Material and method. We performed a study in a university hospital and its dialysis unit. Design: Prospective open efficacy study of a postoperative diagnostic monitoring method of intact parathyroid hormone (iPTH) in a cohort of surgical patients without loss to follow-up. Patients and interventions: Thirty-five patients (19 women and 16 men) underwent TPT and SCPTx for RHP at the Department of General Surgery and Department of Nephrology, Donostia Hospital, San Sebastián, Gipuzkoa, Spain, from January 2002 to December 2005. Follow-up ranged from 6 to 42 months (mean, 15.4 months). Graft function was evaluated by measurement of plasma iPTH levels before surgery and 24 hours and 1, 3, 5, 15, 30, 60, 100 and 150 weeks after surgery. Reference values for PTH in our laboratory were 20-65 pg/mL. Results. The mean preoperative iPTH values were 1245 ± 367.9 pg/mL (mean ± SD) (range, 493-2160). After TPT and SCPTx, iPTH levels became undetectable in all patients at 24 hours. A value of 50 pg/mL was established as the criterion for adequate parathyroid graft function. The following values were obtained: 15.54 ± 10.61 pg/mL (mean ± SD) (range, 6-44) after 1 week, 57.2 ± 1.9 pg/mL (mean ± SD) (range, 43-74) after 5 weeks, 64.21 ± 9.73 pg/mL (mean ± SD) (range, 11.3-89) after 15 weeks, 75.12 ± 9.05 pg/mL (mean ± SD) (range, 24.6-104.2) after 30 weeks, 101.63 ± 19.85 pg/mL (mean ± SD) (range, 65-143) after 60 weeks, 121.63 ± 27.85 pg/mL (mean ± SD) (range, 62-179) after 100 weeks, 63 ± 19.85 pg/mL (mean ± SD) (range, 68-723) after 150 weeks and 102 ± 18.65 pg/mL (mean ± SD) (range, 68-113) after 200 weeks. The prevalence of hypoparathyroidism (serum iPTH level of < 20 pg/mL with a normal or low serum calcium concentration) was 2 out of 35 patients (5.71%) by week 60, with recovery of normal values by week 100. Graft-related recurrence occurred in one out of 35 patients (2.85%). Conclusions. SCPTx after TPT and PTx for secondary RHP is an adequate method to replace muscular forearm parathyroid transplantation and avoid its complications. The functional results of TPT and SCPTx compare favorably with published data on other surgical techniques proposed for the treatment of RHP. Long-term follow-up of this series is currently being performed (AU)

Cirugía endoscópica subcutánea en urología / Subcutaneous endoscopic surgery in Urology

Objetivo: La cirugía endoscópica subcutánea consiste en la insuflación con anhídrido carbónico para crear un espacio de trabajo, evitando de esta forma una incisión. Esta técnica está imponiéndose hasta el extremo de que hoy en día gran parte de la cirugía de la cara, cuello y mama se hacen por esta vía. Sin embargo esta cirugía todavía no ha llegado a la región del conducto inguinal ni al escroto, cuyo abordaje vamos a describir. Métodos: En cuanto a la vía inguinal, introducimos 3 trócares de 5 mm, disecamos la fascia del músculo oblicuo externo, identificamos el orificio inguinal superficial y accedemos al escroto. El abordaje escrotal de momento lo hemos realizado sólo en el hidrocele. Para ello endoscópicamente disecamos la capa vaginal sin romperla, la puncionamos, vaciamos el contenido líquido y por último la resecamos y la extraemos. Resultados: Por vía inguinal hemos operado 3 quistes y un tumor sólido de cordón y por vía escrotal, hemos operado 6 hidroceles. Esta breve estadística nos ha permitido confirmar, que no hay especial dificultad técnica, que el tiempo operatorio es breve y que posiblemente el dolor postoperatorio es menor. Conclusiones: Aunque la cirugía endoscópica subcutánea en Urología está en sus comienzos, los resultados hasta la fecha han sido excelentes y estamos convencidos de que las indicaciones irán ampliándose (AU)

Objectives: In endoscopic subcutaneous surgical procedures, new to Urology, the subcutaneous tissues are insufflated with carbon dioxide through a trocar to create working space without a surgical incision. Although this technique now predominates in surgery of the face, neck and breast, from the literature it appears that it has not yet been adopted for surgery in the region of the inguinal canal or in the scrotum. We describe these approaches. Methods: To carry out the inguinal canal approach we introduced three 5mm trocars and dissected the external oblique fascia until we identified the superficial inguinal ring and gained access to the scrotum. The scrotal approach is directly into the scrotum. To date, we have only used the scrotal approach to treat hydroceles. We carefully detached the tunica vaginalis from the scrotal wall and kept the tunica intact before puncturing it to empty the fluid contents. The tunica was then resected and withdrawn through a trocar. Results: We have removed three cysts and one solid tumor of the spermatic cord with the inguinal approach. With the scrotal approach we have treated six hydroceles. Our experience with these two small series allows us to confidently state that the procedure offers no particular technical difficulty; that operating times are short and that post-operative pain is very probably less than usual. Conclusions: Although endoscopic subcutaneous surgery in Urology is in its infancy, our results until now have been excellent and permit us to conclude that in the future there will be more indications for this type of surgery (AU)

[Essentials aspects of robotic systems]. / Aspectos esenciales de los sistemas robóticos urológicos.

OBJECTIVES: Most advances in Surgery can now be seen to have been preceded by the invention of new instruments. Conventional surgery progressed as new instruments became available. Transurethral resections became routine following the introduction 80 years ago of the resectoscope: a highly revolutionary instrument at that time. Ureterorenoscopes and nephros- copes opened new windows of opportunity for urologists. When the therapeutic potential of extracorporeal lithotripsy, was first mentioned in the literature most surgeons thought it was mere science-fiction fantasy. Very soon however, this new technique, the fruit of close collaboration between urologists and engineers, became a common-place reality. Laparoscopy met with similar disbelief and the early applications gave rise to controversy and even consternation, yet only a few years later most of our urological surgical procedures have adopted this technique. METHODS: At the beginning of the 20th century the astounding advances in engineering led many to forecast that before its end those systems might mimic human intelligence. However, many attempts to construct a rational thinking device revealed that even today this ambitious project was a still an unattainable dream. Consequently, attempts to design an autonomous urological surgical robot that might carry out unsupervised transurethral resections were unfruitful because the inherent and unpredictable complexity of surgical procedures obliges close and rigorous control by the surgeon. This important limitation led to the creation of 'master-slave' systems similar to those designed by our team in 1998 for transurethral resection. These are relatively simple tools and are infinitely safer than autonomous robots because they aim to effectively help the surgeon rather than replace him. RESULTS/CONCLUSIONS: The oft-repeated argument about whether or not a robot might ever replace the surgeon now has little sense because today it is merely a tool, an instrument for the surgeon's hands. The devices available today lack the all-important tactile feedback and to use them effectively, the surgeon is obliged to serve a new and arduous apprenticeship and the learning curve is unavoidably steep. Consequently, many prestigious authors understandably feel unable to recommend their use. Our accumulated experience with master-slave manipulators stimulates us to confidently predict that sooner than later, whether we like it or not, surgical robots will evolve to become indispensable tools that enhance the surgeon's skill, precision and speed in many surgical procedures.

Parathyroid subcutaneous pre-sternal transplantation after parathyroidectomy for renal hyperparathyroidism. Long-term graft function.

BACKGROUND: In the setting of total parathyroidectomy (TPT) and parathyroid transplantation (PTx) for renal hyperparathyroidism (RHP), we evaluated long-term parathyroid graft function after subcutaneous pre-sternal transplantation (SCPTx). Because parathyroid glands are surrounded by fatty tissue, we postulated that results of subcutaneous implantation of parathyroid tissue after total parathyroidectomy for renal hyperparathyroidism could be at least as successful as intramuscular grafting, but without its complications. PATIENTS AND METHODS: The study, a prospective open efficacy study of postoperative (po) diagnostic monitoring of intact parathyroid hormone (iPTH) on a cohort of surgical patients, was conducted within a university hospital with a dialysis unit. Thirty five patients (19 women and 16 men) operated on for renal hyperparathyroidism underwent TPT and SCPTx for RHP at the Department of General Surgery and the Department of Nephrology. Donostia Hospital. San Sebastián. Gipuzkoa. Spain, from January 2002 to December 2005. Follow-up ranges from 6 months to 42 months (median: 15.4 months). The main outcome measure was evaluation of graft function by measurement of iPTH plasma level, based on serum levels of iPTH before operation and 24 h and 1, 3, 5, 15, 30, 60, 100, and 150 weeks after surgery. RESULTS: Average preoperative iPTH values were 1,341.52 + 367.78 pg/ml (mean +/- SD) (range: 493-2,180). After TPT and PSCTx, iPTH levels became undetectable in all patients at 24 h. A level of 50 pg/ml was established as the criterion of adequate parathyroid graft function. Values obtained at the various time intervals were as follows: 14.14 + 7.73 1 pg/ml (mean +/- SD) (range: 6-36) after 1 week, 53 + 77.33 pg/ml (mean +/- SD) (range: 35-74) after 5 weeks, 62.95 + 20.93 pg/ml (mean +/- SD) (range: 11-89) after 15 weeks, 77.54 + 18.84 pg/ml (mean +/- SD) (range: 24.6-104.2) after 30 weeks, 109.29 + 50.22 pg/ml (mean +/- SD) (range: 54-327) after 60 weeks, 134.21 + 128.64 pg/ml (mean +/- SD) (range: 43-712) after 100 weeks, and 122.84 + 117.54 pg/ml (mean +/- SD) (range: 68-723) after 150 weeks. Prevalence of hypoparathyroidism (intact parathyroid hormone serum level < 20 pg/ml with a normal or low serum calcium concentration) was 2/35 (5.71%) by week 60 and recovered by week 100. Graft-related recurrence was 2.85% (1/35). CONCLUSIONS: Subcutaneous pre-sternal transplantation (SCPTx) after TPT and PTx for secondary (RHP) is an adequate method to replace muscular forearm parathyroid transplantation and avoid its complications. Functioning results of total parathyroidectomy and presternal subcutaneous grafting compare favorably with the published data on other surgical techniques proposed for the treatment of renal hyperparathyroidism. Results of long-term follow-up exceed previously reported results.

Aspectos esenciales de los sistemas robóticos urológicos / Essentials aspects of robotic systems

Objetivo: Desde la antigüedad los adelantos en medicina se deben en gran parte a las herramientas utilizadas. Para la cirugía convencional se necesita un instrumental, igual ocurre con la resección transuretral que precisa de un resector, que fue un instrumento muy avanzado para la época en la que se creó. Lo mismo sucede con la ureterorrenoscopia o la nefroscopia. La litotricia extracorpórea surgió gracias a la estrecha colaboración entre ingenieros y urólogos, lo que supuso una auténtica revolución en la medicina. La laparoscopia ha dado lugar a una conmoción si cabe mayor, ya que gran parte de nuestra cirugía ha habido que adaptarla a esta nueva técnica. Métodos: Los grandes avances tecnológicos habidos a principios del siglo XX hicieron pensar que a finales de siglo estos sistemas serían capaces de imitar a la inteligencia humana, pero al intentar fabricar una mente racional se llegó a la conclusión de que conseguir que estos instrumentos tomaran decisiones suponía un desafío monumental inviable hoy en día. Por ello, ya dentro de la Urología, el intento de crear un robot autónomo para la resección transuretral fracasó, porque la complejidad de un procedimiento quirúrgico requiere un estricto y riguroso control por parte del cirujano. Ello dio lugar a los sistemas maestro-esclavo, como el diseñado por nosotros en 1998 para la resección transuretral, que son simples herramientas, infinitamente más seguras que el robot independiente, que facilitan el trabajo del cirujano pero que no lo sustituyen. Resultados/conclusiones: La reiterada polémica de que si los robots van a sustituir al cirujano no tiene sentido, porque de momento son tan sólo simples instrumentos. Los manipuladores existentes hoy en día, al carecer de sensibilidad táctil, tienen una larga curva de aprendizaje. Todo ello hace que por ahora no pocos autores de prestigio desaconsejen su uso. Sin embargo nosotros estamos convencidos de que, antes de que lo imaginemos, lo queramos o no, los robots en cirugía serán instrumentos obligados e imprescindibles y de que su uso se habrá generalizado (AU)

Objectives: Most advances in Surgery can now be seen to have been preceded by the invention of new instruments. Conventional surgery progressed as new instruments became available. Transurethral resections became routine following the introduction 80 years ago of the resectoscope: a highly revolutionary instrument at that time. Ureterorenoscopes and nephroscopes opened new windows of opportunity for urologists. When the therapeutic potential of extracorporeal lithotripsy, was first mentioned in the literature most surgeons thought it was mere science-fiction fantasy. Very soon however, this new technique, the fruit of close collaboration between urologists and engineers, became a common-place reality. Laparoscopy met with similar disbelief and the early applications gave rise to controversy and even consternation, yet only a few years later most of our urological surgical procedures have adopted this technique. Methods: At the beginning of the 20th century the astounding advances in engineering led many to forecast that before its end those systems might mimic human intelligence. However, many attempts to construct a rational thinking device revealed that even today this ambitious project was a still an unattainable dream. Consequently, attempts to design an autonomous urological surgical robot that might carry out unsupervised transurethral resections were unfruitful because the inherent and unpredictable complexity of surgical procedures obliges close and rigorous control by the surgeon. This important limitation led to the creation of ‘master-slave’ systems similar to those designed by our team in 1998 for transurethral resection. These are relatively simple tools and are infinitely safer than autonomous robots because they aim to effectively help the surgeon rather than replace him. Results/conclusions: The oft-repeated argument about whether or not a robot might ever replace the surgeon now has little sense because today it is merely a tool, an instrument for the surgeon’s hands. The devices available today lack the all-important tactile feedback and to use them effectively, the surgeon is obliged to serve a new and arduous apprenticeship and the learning curve is unavoidably steep. Consequently, many prestigious authors understandably feel unable to recommend their use. Our accumulated experience with master-slave manipulators stimulates us to confidently predict that sooner than later, whether we like it or not, surgical robots will evolve to become indispensable tools that enhance the surgeon’s skill, precision and speed in many surgical procedures (AU)