Robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy for metastatic mixed testicular germ cell cancer: a case report.

BACKGROUND: The robot-assisted laparoscopic management of post-chemotherapy retroperitoneal metastasis and inferior vena cava tumor thrombus secondary to testicular cancer is a challenging task for urologists. CASE PRESENTATION: A pathological examination of a 36-year-old Caucasian man who had undergone a right radical orchiectomy showed mixed testicular germ cell cancer (70% embryonal cancer and 30% seminoma); he had undergone four prior courses of cisplatin, etoposide, and bleomycin chemotherapy and was found to have residual retroperitoneal enlarged lymph nodes close to the right renal hilum and a 9.8 cm inferior vena cava tumor thrombus (pT1, N2, M1, S2). Pre-surgical three-dimensional image reconstruction was performed based on contrast computed tomography data. The inferior vena cava tumor thrombus was found in the vena cava at the level of the celiac trunk and the inferior mesenteric artery. Our patient accepted treatment with robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy and cava reconstruction on September 12, 2018. During the procedure, a drop-in robotic ultrasound probe was used to define the thrombus. Vena cavoscopy using a flexible ureteroscope found that the tumor thrombus adhered to the cava wall in all directions. The tumor thrombus was dissected free from the inferior vena cava lumen, and vena cava reconstruction was achieved using the da Vinci™ Si HD surgical system. The operative time was 550 minutes. The intraoperative estimated blood loss was 2300 ml. Intraoperative blood transfusions consisted of 10 units of red blood cells (Clavien-Dindo grade II). No Clavien-Dindo grade III or above perioperative complications occurred. The length of hospital stay was 7 days. Pathology revealed no viable cancer cells in any of the residual lymph node tissues or in the vena cava tumor thrombus. CONCLUSION: This is the first case of robot-assisted laparoscopic retroperitoneal lymph node dissection with concomitant inferior vena cava thrombectomy and reconstruction for metastatic mixed testicular germ cell cancer published to date. This complicated surgical procedure was facilitated by the innovative usage of three-dimensional image reconstruction for defining the vena cava tumor thrombus, a robotic ultrasound probe for intraoperatively defining the vena cava tumor thrombus, and vena cavoscopy using a flexible ureteroscope.

Methylene blue staining for nerve-sparing operative procedures: an animal model.

OBJECTIVES: To evaluate methylene blue fiber staining as a method of nerve fiber identification in an animal model, because the maintenance of organ function after surgery depends on exact intraoperative identification of the relevant nerve fibers. METHODS: Brindley electrodes were implanted bilaterally at S3 for sacral anterior root stimulation in six minipigs. For reference, stimulation-induced detrusor contractions were recorded urodynamically. After exposure of the ureterovesical junction on both sides, a 2:8 methylene blue solution was applied to the right side; the left side remained untreated. Bilateral dissection of the ureter from the surrounding tissue for a distance of 4 cm proximal to the ureterovesical junction was performed. The methylene blue-stained nerve fibers on the right side were spared; no particular attention was paid to the nerves on the left. Again, sacral anterior root stimulation-induced detrusor contractions were monitored urodynamically on both sides. Then, the identified nerve fibers on the right were cut intentionally, and the detrusor pressure was recorded again under stimulation. Finally, the dissected nerve structures were evaluated histologically. RESULTS: The reference bladder pressures after unilateral stimulation on the left side before ureter dissection showed a mean detrusor pressure (Pdet) of 19 cm H2O. On the right side, the Pdet was 18 cm H2O. After preparation on both sides, a mean Pdet of 3 cm H2O was recorded after left side stimulation, and a Pdet of 17 cm H2O after right side stimulation. When the stained nerve fibers on the right side were cut, no bladder contractions could be induced. The histomorphology of the stained and dissected structures revealed multiple autonomous nerve fibers and small vessels in connective tissue. CONCLUSIONS: The identification of minute nerve bundles is a tedious and difficult task. The results from our animal model demonstrated that supravital staining of autonomous nerve fibers with methylene blue is a simple and reliable method of identification.

Restoration of external urethral sphincter function after pudendal nerve end-to-end anastomosis in the male rabbit.

PURPOSE: In this study we rehabilitated external urethral sphincter function by pudendal nerve end-to-end anastomosis after experimental pudendal nerve axotomy in male rabbits. MATERIALS AND METHODS: A total of 17 animals were included in this study, including group 1-a control group of 5 (29.4%), group 2-6 (35.3%) and group 3-6 (35.3%). Animals from group 2 underwent bilateral axotomy and group 3 underwent pudendal nerve end-to-end anastomosis. In all groups we performed urodynamic investigations prior to axotomy, after axotomy or anastomosis, and 14, 42 and 90 days after axotomy or nerve anastomosis. RESULTS: In untreated group 1 control sphincter pressure was 28.5 cm H2O. In group 2 average urethral sphincter pressure was 5.6 cm H2O 14 days after axotomy with only a slight increase to 11.05 cm H2O by day 90. In group 3 external urethral pressure increased to 8.26 cm H2O after 14 days and to 21.32 cm H2O by postoperative day 90. CONCLUSIONS: External urethral sphincter deficiency after bilateral pudendal nerve axotomy demonstrates the primacy of the pudendal nerve in the innervation of the external urethral sphincter. We were able to rehabilitate external urethral sphincter function by performing pudendal nerve end-to-end anastomosis.

[Continuous bilateral sacral neuromodulation as a minimally invasive implantation technique in patients with functional bladder changes]. / Neuromodulación crónica sacra bilateral con una técnica de implantación mínimamente invasiva en pacientes con alteraciones funcionales de la vejiga.

OBJECTIVE: Up to 50% of patients with bladder dysfunctions undergoing sacral neuromodulation treatment are non-responders. The most common treatment method today is the implantable neuromodulation system described by Tanagho and Schmidt; which allows unilateral sacral nerve stimulation. Our aim was to increase the number of responders and to improve the general efficiency of chronic sacral neuromodulation; therefore we have developed the bilateral electrode implantation by minimally invasive laminectomy. METHODS: PNE-tests were carried out to assess which patients were likely to be good responders. Thirty patients (16 with detrusor instability, 14 with hypocontractile detrusors) were subjected to minimally invasive laminectomy and received implants of bilateral electrodes. RESULTS: In those patients with a hyopcontractile detrusor, the level of residual urine of initially 350 ml was reduced to 58 ml, and the maximum detrusor pressure during micturition increased from initially 12 cMH2O to 34 cmH2O. In the other patient group with detrusor instability, the average number of incontinence incidences could be reduced from initially 7.2 to 1 per day, while the bladder capacity rose from 198 ml to 348 ml. The modulation effect did not show any signs of deteriorating in any of the patients. The follow-up period was 28 months on average. CONCLUSIONS: Clinical experience has shown that optimal neuromodulation in patients with bladder dysfunction can be achieved by this new approach involving bilateral electrode implantation. Moreover, the laminectomy implantation method guarantees a minimum of invasive trauma and enables optimal placement and fixation of the electrode.

Polytetrafluoroethylene versus polypropylene sutures for Essed-Schroeder tunical plication.

PURPOSE: Essed-Schroeder plication is an established operative technique to correct congenital and acquired penile deviation. However, a third of all patients complain about discomfort from the suture material used. We prospectively evaluated patient satisfaction and quality of life after modified Essed-Schroeder plication by comparing 2 suture materials. MATERIALS AND METHODS: Between 1998 and 2001, 88 patients underwent surgical correction of penile deviation at our hospital. Mean patient age was 40 years (range 18 to 71) and mean followup was 30 months. Preoperatively penile curvature was greater than 20 degrees in all patients. A standardized questionnaire was sent to all patients. A total of 55 patients, including 30 with Peyronie's disease (PD) and 25 with congenital penile deviation (CPD), were available for evaluation and had complete followup. RESULTS: In 25 of these patients (12 with PD and 13 with CPD) nonabsorbable polypropylene (PP) sutures were used for plication, whereas in the other 30 (18 with PD and 12 with CPD) nonabsorbable polytetrafluoroethylene (PT) sutures were used. In the PP group 22 of the 25 patients (88%) could notice the sutures (11 with PD and 11 with CPD), 10 had discomfort (6 with PD and 4 with CPD) and 3 had pain during penile erection (2 with PD and 1 with CPD). In the PT group 15 of the 30 patients (50%) could notice the sutures (10 with PD and 5 with CPD), 3 had discomfort (1 with PD and 2 with CPD) and 1 with PD had painful erections. Three patients had recurrent deviation, of whom 2 and 1 underwent plication with PP and PT, respectively. CONCLUSIONS: These results indicate the PT is the more superior suture material with regard to postoperative patient discomfort after Essed-Schroeder correction of penile deviation. Nonabsorbable PT sutures do not impair the efficacy of the modified Essed-Schroeder plication technique and the success rate is not related to the underlying pathological condition.

Risk of detrusor denervation in antireflux surgery demonstrated in a neurophysiological animal model.

PURPOSE: Earlier anatomical studies have shown a close connection between the ureterovesical junction and detrusor innervation. It prompted us to develop an animal model to demonstrate the risk of partial or complete impairment of this neuronal connection during antireflux surgery. MATERIALS AND METHODS: Six female Göttinger minipigs were anesthetized and laminectomized. After placement of the S3 sacral nerves into separate electrode compartments of a modified Brindley electrode the lower urinary tract was exposed by an abdominal midline incision. After bladder instillation with 150 ml NaCl 1 bilateral and 2 unilateral stimulations (left and right sides) were performed and intravesical pressure was recorded urodynamically. The left ureter was then prepared circularly in 3 steps 10, 5 and 1 cm, respectively, proximal to the ureterovesical junction. After each preparation step bilateral and unilateral stimulation was repeated. Results were recorded urodynamically and video documented. RESULTS: Bilateral stimulation before preparation of the left ureter led to a concentric detrusor contraction with an average maximum detrusor pressure of 51 cm H(2)O. Unilateral stimulation resulted in ipsilateralbound bladder tilting with an intravesical pressure of 18 and 19 cm H(2)O on the right and left sides, respectively. After preparation of the left ureter 10, 5 and 1 cm from the ureterovesical junction a maximum detrusor pressure of 17, 10 and 1 cm H(2)O was documented, respectively. While there was almost no stimulation response of the bladder after the last preparation step at 1 cm on the left ureter, the initial bladder pressure of 18 cm H(2)O could be reproduced under stimulation on the right side. CONCLUSIONS: Analogous to human cadaver studies, we were able to prove neurophysiologically strictly unilateral detrusor innervation, drawing from the pelvic plexus dorsomedial to the ureterovesical junction into the bladder. Preparation of this ureterovesical junction during antireflex surgery, coagulating measures in this area or the affixation of anchor sutures after a Vest suture involves the risk of unilateral or bilateral detrusor decentralization.

The role of the carbachol test and concomitant diseases in patients with nonobstructive urinary retention undergoing sacral neuromodulation.

The aim of this study was to evaluate the percutaneous nerve evaluation (PNE) test success in patients with nonobstructive urinary retention. A total of 24 PNE tests were performed in patients with nonobstructive urinary retention and in 18 patients, a carbachol test was performed during urodynamics. The diagnosis relating to the acontractile detrusor was also assessed and compared to the outcome of the PNE test. The PNE test was successful in eight of 24 patients (33.3%) with the the highest success rate being observed in patients after hysterectomy (80%). It was successful in five of 12 patients with negative carbachol tests and in three of six patients with positive carbachol tests. We conclude that sacral neuromodulation is an effective treatment option in patients with nonobstructive urinary retention. PNE tests should be performed in all patients with therapy resistant nonobstructive urinary retention, because predictive factors do not exist.

Neuromodulación crónica sacra bilateral con una técnica de implantaciónmínimamente invasiva en pacientes con alteraciones funcionales de la vejiga / Bilateral chronic sacral neuromodulation with a minimally invasive implantation technique in patients with bladder dysfunction

OBJETIVO: El porcentaje de fracasos con la técnica descrita por Tanagho y Schmidt para la neuromodulación sacra crónica con estimulación unilateral alcanza hasta el 50 por ciento. Con el objetivo de mejorar la efectividad de la modulación, así como el posicionamiento y fijación de los electrodos, hemos optado por la laminectomía sacra mínima con instalación bilateral de electrodos. MÉTODOS: En un total de 30 pacientes (16 con diagnóstico de inestabilidad del detrusor refractaria a terapia y 14 con hipoactividad del detrusor) se implantó un modulador neurológico con instalación de electrodos sacros bilaterales, previa certificación de la indemnidad de los nervios periféricos con el test de evaluación correspondiente. Con el propósito de asegurar una adecuada instalación y fijación de los electrodos se llevó acabo una laminectomía sacra mínima. RESULTADOS: En los pacientes con inestabilidad del detrusor se observó una reducción del promedio de episodios de incontinencia de 7,2 a 1 por día y la capacidad vesical aumentó de 198 a 348 ml. En los pacientes con hipoactividad del detrusor se constató una disminución en los residuos postmiccionales de 350 a 58 ml. La contracción máxima del detrusor durante la micción aumentó de 12 cm H2O a 34cm H2O. El seguimiento promedio fue de 28 meses. No hubo signos de deterioro en el efecto modulador en ninguno de los pacientes. CONCLUSIÓN: La modulación neurológica sacra bilateral, en conjunto con la técnica de implantación mínimamente invasiva desarrollada por nosotros, permite alcanzar resultados óptimos en pacientes con inestabilidad del detrusor refractaria a terapia así como también en pacientes con detrusor hipoactivo (AU)

Preoperatively evaluated bladder wall tension as a prognostic parameter for postoperative success after surgery for bladder outlet obstruction.

OBJECTIVES: To evaluate a novel method for the determination of bladder wall tension (BWT) and to correlate these findings with postoperative persistent residual urine, postoperative uroflow, International Prostate Symptom Score, and quality-of-life index in patients with bladder outlet obstruction. METHODS: In 28 male patients with prostate enlargement or bladder neck sclerosis undergoing surgical treatment, the preoperative BWT was determined after urodynamic investigation and ultrasound determination of bladder weight. The patients were divided into two groups: group 1 (n = 24), postoperative residual urine volume less than 50 mL; and group 2 (n = 4), persistent residual urine volume greater than 50 mL. Five patients in group 1 were unobstructed in accordance with the Abrams-Griffiths nomogram. This group was compared separately with group 2, in which all 4 patients were also classified as unobstructed. RESULTS: The preoperative BWT in group 1 was 5.2 +/- 4.1 N/cm(2), significantly different from the preoperative BWT in group 2 (0.98 +/- 0.3 N/cm(2)). The BWT in the 5 unobstructed patients in group 1 (3.4 +/- 1.3 N/cm(2)) was significantly greater than that in patients in group 2. BWT was the sole parameter that was distinctly different between these 5 patients and the patients in group 2, with a significant influence on postoperative uroflow, International Prostate Symptom Score, and quality-of-life index. CONCLUSIONS: The results of this pilot study show that the determination of BWT allows further evaluation of the detrusor function. Especially in patients classified as unobstructed according to the Abrams-Griffiths nomogram, preoperative determination of the BWT could become a supplemental and important parameter with predictive value for postoperative success in patients with prostate enlargement or bladder neck sclerosis.

[Testosterone substitution in patients with hypogonadism]. / Substitución con testosterona en pacientes con hipogonadismo.

OBJECTIVE: After the age of 60, 20-35% of men present with androgen deficiency. Clinical symptoms of hypogonadism in older men are often more difficult to interpret than in younger men. Knowledge of physiological actions of testosterone and its metabolites are important prerequisites for diagnosis, drug selection and surveillance of therapy. Another question is whether any type of interventions, such as hormone replacement therapy, may play a role in improving the quality of life as proven in post-menopausal women. METHODS: To understand testosterone supplementation in the aging male, this review will discuss the following important topics: physiology of male hormonal balance, changes in reproductive organs in elderly men, endocrine evaluation of the male, pharmacological effects of testosterone on target organs, available preparations for testosterone and testosterone supplementation. RESULTS: Testosterone deficiency may induce organic symptoms such as loss of muscular strength, decreased libido and loss of bone density and have psychological consequences such as fatigue or depression. Controlled clinical trials show that therapy with natural testosterone results in clinical improvements in elderly men that cover androgenic effects. CONCLUSIONS: With the current status of knowledge short acting, low dose testosterone preparations seem to be best tailored for substitution of older hypogonadal men. Only intensive research in the future can satisfy these requirements.

Substitución con testosterona en pacientes con hipogonadismo / Testosterone substitution treatment in patients with hypogonadism

Objetivo: El paulatino decrecimiento de la producción androgénica en el hombre es un fenómeno bien conocido. A partir de los sesenta, entre 20 por ciento y 35 por ciento de los hombres presentan una deficiencia androgénica. La interpretación de los síntomas clínicos en estos hombres puede resultar mucho más difícil que en hombres jóvenes. Por eso es crucial estudiar y comprender la función de la testosterona y sus metabolitos, más si queremos seleccionar un medicamento para la terapia hormonal de una diagnosticada insuficiencia androgénica. Con este trabajo queremos dar repuesta a la pregunta si la substitución con testosterona realmente lleva a un aumento de calidad de vida, como se ha comprobado para las mujeres en la post-menopausia. Métodos: Para poder entender la suplementación con testosterona en el hombre de avanzada edad, este trabajo de revisión discute los siguientes puntos: fisiología del balance hormonal masculino, cambio fisiológico en el sistema reproductivo del hombre de avanzada edad, efectos farmacológicos de la testosterona en los órganos de destino, las formas diferentes de aplicar testosterona y la suplementación de testosterona en general. Resultados: Hasta el momento indican todos los estudios controlados que la suplementación con testosterona, favorece al hombre de avanzada edad en múltiples factores como en la vida sexual (libido, función eréctil), composición corporal, metabolismo del hueso y psicológicos. Conclusión: La substución racional y adecuada con testosterona favorece al hombre hipogonadal sin una perjuicio general (AU)

[Methylene blue: an effective therapeutic alternative for priapism induced by intracavernous injection of vasoactive agents]. / Azul de metileno: una efectiva alternativa terapéutica para el priapismo inducido por inyección intracavernosa de sustancias vasoactivas.

OBJECTIVE: Priapism is defined as prolonged and persistent erection of the penis without sexual stimulation. Etiologies of this condition are numerous. Recent advances in the understanding of erectile physiology have improved the prompt diagnosis and treatment of priapism. Treatment of priapism varies from a conservative medical to a drastic surgical approach. Normally, priapism is effectively treated with intracavernous vasoconstrictive agents or surgical shunting. Recent findings indicate methylene blue (MB), a guanylate cyclase inhibitor, to be a potential inhibitor of endothelial-mediated cavernous relaxation. This prompted us to assess the feasibility, the use and the effectiveness of MB in the treatment of priapism. METHODS: 25 patients were treated for priapism. Etiologies were: 22 drug-mediated (PGE1 or papaverine/phentolamine mixture) after corpus cavernosum injection therapy (CCIT), 1 leukemia-induced and 2 idiopathic high-flow priapism. Patient ages ranged from 13 to 72 years. The average duration of priapism was 5 hours and 22 minutes after CCIT. MB was administered after blood aspiration of the corpora cavernosa. 5 ml of MB was injected intracavernously (i.c.) and left for 5 min. MB was then aspirated and the penis compressed for an additional 5 min. RESULTS: All patients with CCIT-induced priapism were cured with MB alone. The 3 patients who did not respond to MB underwent i.c. phenylephrine administration and finally, if necessary, embolization of the pudendal artery. Etiology and duration of priapism were the strongest predictors for success with intracavernously administered MB. The primary side effects were a transient burning sensation and blue discoloration of the penis on injection of MB. The initial baseline erectile status was restored in all patients cured by MB. CONCLUSIONS: These results confirm that MB is a safe and highly effective treatment agent for short-term pharmacologically-induced priapism. Furthermore, MB demonstrates distinct advantages over a-adrenergic agents for intracavernous use, such as lower costs, absence of systemic or local toxic side effects and shorter treatment time leading to faster detumescence. For this reason, MB is a suitable and safe substance for alternative routine intracavernous therapy in males with pharmacologically-induced priapism.

[Frequency and cause of death in patients with testicular germinal tumors at our center: retrospective analysis]. / Frecuencia y causa de mortalidad en pacientes con tumores germinales del testículo en nuestro centro: un análisis retrospectivo.

OBJECTIVE: The introduction of cisplatin in testis cancer therapy significantly reduced the mortality rate. However, data from previous studies indicate that mortality is higher than expected. The aim of our retrospective study in a single center was to evaluate the mortality rate of testicular germ cell tumors. Further to this, a failure analysis was carried out to determine the cause of death, taking the compliance of both the patient and clinician into consideration. METHODS: The mortality rate was evaluated in patients referred to and/or treated for testis cancer at the Department of Urology of the Mannheim University Hospital between 1986 and 2000. The causes of death were determined in this group of patients and divided into four categories: 1) death from tumor progression without management failure, 2) death caused by toxicity or side effects of the treatment, 3) death from poor patient compliance, 4) death from poor compliance of the clinician. RESULTS: There were 16 deaths in 139 patients treated up to 2000 (mortality rate 11.5%). The causes were determined as tumor progression and toxicity in 19%. In 31% of the cases, poor compliance of both patient and clinician contributed significantly to the cause of death. CONCLUSIONS: Our study supports the theory that negligence to follow the guidelines specified for the treatment of testis cancer may be related to the death of patients with this disease. This could be an explanation for the discrepancy between the expected and actual mortality rate. The quality management of testicular cancer by further standardized failure analysis could reduce the mortality rate.

Frecuencia y causa de mortalidad en pacientes con tumores germinales del testículo en nuestro centro: un análisis retrospectivo / Incidence and cause of mortalitu in patients with germ cell testicular tumor in our setting: A retrospective analysis

OBJETIVO: La introducción del cisplatino permitió reducir en forma significativa la mortalidad del cáncer testicular. Diversos datos proporcionados por estudios previos apuntan a que fallecen más pacientes de lo inicialmente proyectado. MÉTODO: Se efectuó un análisis retrospectivo unicéntrico con el objetivo de determinar la tasa de mortalidad. Por otro lado, se estudiaron las causas de mortalidad, considerando para este fin la adherencia a la terapia por parte del paciente, así como por parte del médico. Se calculó la tasa de mortalidad de pacientes tratados por tumores testiculares de células germinales en el Servicio de Urología del Hospital Universitario de Mannheim en el período comprendido entre 1986 y 2000.Para el grupo de pacientes fallecidos en el período 1986-2000 se identificaron factores diagnósticos y terapéuticos determinantes para el desenlace fatal de su enfermedad. Para este efecto se clasificaron las causas de mortalidad en 4 categorías: muerte por progresión de la enfermedad sin error de manejo, muerte por toxicidad y/o efectos colaterales de la terapia, muerte por falta de adherencia a la terapia por parte del paciente y por último muerte por falta de adherencia a la terapia por parte del médico. RESULTADOS: De 139 pacientes tratados y con un seguimiento completo hasta 2000 fallecieron 16 (11,5 por ciento).El progreso de la enfermedad, al igual que la toxicidad de la terapia, contribuyeron en un 19 por ciento a las causas de mortalidad. Por otro lado, tanto la falta de adherencia por parte del médico, como por parte del paciente, contribuyeron en un 31 por ciento a las causas de mortalidad. CONCLUSIÓN: Estos estudios sugieren que la poca rigurosidad en mantener procedimientos terapéuticos estandarizados puede influir en la mortalidad de los pacientes. Esto podría explicar la discrepancia existente entre la tasa de mortalidad proyectada y la registrada. El empleo de "análisis de errores" como el utilizado en este estudio, contando de esta manera con un método de control de calidad del manejo del cáncer testicular, podría contribuir a disminuir la mortalidad de esta patología (AU)

Tratamiento de la urolitiasis en niños y adolescentes mediante litotricia extracorpórea y procedimientos urológicos auxiliares / Treatment of urolithiasis in children and adolescent with extracorporeal shock wave lithotripsy and auxiliary urological procedures

OBJETIVO: El objetivo de este trabajo fue plantear la eficiencia de litotricia extracorpórea por ondas de choque ( LEOC ) en niños y la frecuencia de la utilización de otros procedimientos urológicos auxiliares para el manejo de la urolitiasis. Para ello se llevo a cabo un análisis retrospectivo de la evolución de los niños posterior a LEOC mediante el conteo del número de complicaciones y medidas auxiliares adicionales utilizadas, así como los casos libres de cálculos. MÉTODOS: De enero del 90 a enero del 99 se trataron 56 cálculos en totalidad (28 niñas y 21 niños). Las litotricias se realizaron con una máquina Lithostar Plus y una Modulith SL20/SLX. Las medidas auxiliares adicionales utilizadas, se clasificaron como curativas (ureterorrenoscopias y nefrolitolapaxias percutáneas) y adyuvantes (colocación de catéteres ureterales y nefrostomías). RESULTADOS: Posterior a la primer LEOC el 34,7 por ciento de los niños resultaron libres de cálculos residuales, en el 40,8 por ciento de los niños los fragmentos posteriores a LEOC tuvieron las dimensiones adecuadas para expulsarse espontáneamente, el 24,5 por ciento de los pacientes se sometieron nuevamente a una LEOC. Otras medidas urológicas auxiliares adicionales, fueron necesarias en el 28,6 por ciento de los casos (18,3 por ciento adyuvantes y 10,3 por ciento curativas). CONCLUSIÓN: La litotricia por ondas de choque extracorpóreas, es también en los niños una terapia para la litiasis, altamente efectiva. No obstante son necesarias medidas de auxilio adicionales tanto curativas como adyuvantes.Para obtener un alto promedio de éxito y bajo porcentaje de complicaciones es necesario que la LEOC, se lleve a cabo en un centro en el cual exista bastante experiencia, tanto en LEOC como en procedimientos endourológicos en niños (AU)

Influencia del Profesor Alexander von Lichtenberg (Berlín) en la Urología Española del siglo XX / Influence of Professor Alexander von Lichtenberg (Berlin) on Spanish Urology of the 20th century

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Diagnóstico y opciones terapéuticas de la erección prolongada y el priapismo: revisión actualizada / Diagnosis and treatment options of prolonged erection and priapism: A review

La erección prolongada y el priapismo constituyen urgencias urológicas por lo que deben ser resueltas en forma precoz. La conducta expectante es válida sólo durante las primeras 6 horas después de iniciado el evento, ya que a partir de ese momento pueden aparecer lesiones de carácter irreversible en los cuerpos cavernosos. El objetivo terapéutico, esto es la detumescencia completa con la consiguiente recuperación de la irrigación arterial, puede obtenerse en la mayoría de los casos a través de un manejo sistemático y estandarizado. Para estos efectos pueden utilizarse sedantes, agonistas alfa-adrenérgicos o Hidroclorato de Ketamina. Sin embargo, ante una erección persistente, y dada la limitante del tiempo, debieran priorizarse los métodos terapéuticos de aplicación intracavernosa de antídotos. Dentro de éstos existen sustancias convencionales como los agonistas a-adrenérgicos además de otras alternativas como por ejemplo el Azul de Metileno. En esta etapa del proceso debiera existir certeza, a través de un estudio metabólico y hemodinámico, de la genésis etiopatológica del priapismo, ya que las eventuales medidas terapéuticas a partir de este momento se decidirán de acuerdo a la causa del trastorno. En el caso del priapismo de bajo flujo, de mecanismo venooclusivo, debe efectuarse un shunt derivativo si la aspiración intracavernosa de sangre no ha tenido éxito. Por otro lado, en el caso del priapismo de alto flujo persistente, las terapias disponibles son la embolización arterial y la ligadura quirúrgica (AU)