[Benign retroperitoneal schwannoma, laparoscopic ressection]. / Schwanoma retroperitoneal benigno, exéresis por laparoscopia.

Schwannomas are tumors rarely localized in the retroperitoneum, generally appear in craneal as well as periferic nerves. Seldom cases the diagnosis is preoperatively made just because imaging is very poor in this field. MRI is proven to be the diagnostic method. Radical surgical ressection is standarized treatment. We document a case of a benign retroperitoneal schwannoma where we explain the laparoscopic ressection of this kind of tumors for first time.

Cistectomía radical laparoscopica en los tumores vesicales clínicamente localizados. (T2) / Laparoscopic radical cystectomy in clinically localized (T2) bladder tumors

Objetivo: La cistectomía radical laparoscópica se ha desarrollado a partir de la expansión de la prostatectomía radical laparoscópica. Esta técnica permite un abordaje poco invasivo para el tratamiento de los tumores vesicales infiltrantes de la capa muscular con disminución del sangrado y una más rápida recuperación postoperatoria. Métodos: Entre septiembre de 2004 y enero de 2007 se han realizado 54 cistectomías radicales por vía laparoscópica, 48 en estadio T2 y de estas últimas 43 (90%) eran varones y 5 (10%) mujeres. La edad media fue de 64 años (27-88a). La linfadenectomía se practicó por acceso laparoscópico en todos los casos, obteniendo una media de 13 ganglios (4-24). La derivación urinaria se realizó por la incisión de extracción del espécimen en todos los casos menos uno que se realizó completamente intracorpóreo, siendo ureteroileostomía cutánea tipo Bricker en 30 casos (62%), neovejiga ortotópica tipo Padovana en 17 casos (35%) y ureterostomía cutánea en un caso (2%). Resultados: El tiempo quirúrgico medio de todo el procedimiento fue de 287 minutos (180-480), 270 minutos para los casos con derivación tipo Bricker y de 316 para los casos con una neovejiga. El índice de transfusión fue del 25%. El tiempo medio de íleo paralítico fue de 5 días (2-10d) con un tiempo medio de ingreso para los pacientes con Bricker de 13 días (6-34) y de 16 días (8-30) para las neovejigas. El control oncológico, con un seguimiento medio de 10,8 meses (0,4-30m), presenta una supervivencia cáncer específica del 90% con un tiempo medio de supervivencia estimado de 28 meses (IC 95% 26-30). La supervivencia media global ha sido del 79% con un tiempo de supervivencia de 26 meses (IC 95% 23-29). Conclusiones: La cistectomía radical laparoscópica es una técnica factible que ofrece ventajas. Permite una exéresis con un menor sangrado y un postoperatorio más llevadero. Estudios aleatorizados deberían demostrar estas ventajas para confirmar si puede llegar a ser la técnica de elección. La realización de la derivación urinaria por la laparotomía, obligada para la extracción de la pieza quirúrgica, optimiza los resultados de la derivación y el tiempo quirúrgico total sin reducir los beneficios de la exéresis laparoscópica (AU)

Objectives: Laparoscopic radical cystectomy has been developed after the expansion of laparoscopic radical prostatectomy. This technique makes possible a minimally invasive approach to muscle-invasive bladder cancer with less blood loss and faster postoperative recovery. Methods: From September 2004 to January 2007, 54 laparoscopic radical cystectomies were performed, 48 of them in stage T2, from which 43 (90%) were male and 5 (10%) female patients. Mean age was 64 years (27-88). Lymphadenectomy was carried out by laparoscopic approach in all cases, with a mean of 13 nodes obtained (4-24). Urinary diversion was done through the incision needed to extract the specimen in all cases but one that was completed completely intracorporeally; constructing a Bricker-type ureteroileostomy in 30 (62%) cases, orthotopic neobladder (Vesica Ileale Padovana) in 17 cases (35%), and cutaneous ureterostomy in 1 case (2%). Results: Mean surgical time for the whole procedure was 287 minutes (180-480), 270 minutes for Bricker-type derivation cases and 316 minutes for neobladder cases. Blood transfusion rate was 25%. Mean ileal paralysis was 5 days (2-10) with a mean hospital stay of 13 days (6-34) for Bricker cases and 16 days (8-30) for neobladder cases. Oncological control, after a mean follow-up of 10,8 months (0,4-30), showed a cancer-specific survival of 90% with a mean survival time of 28 months (95% CI 26-30). Global mean survival was 79% with a mean survival of 26 months (95% CI 23-29). Conclusions: Laparoscopic radical cystectomy is a feasible technique that offers some advantages. It allows excision with less blood loss and an easier postoperative period. Randomized studies should demonstrate these advantages to confirm this approach as the technique of choice. Urinary diversion performed through the laparotomy incision, necessary to extract the specimen, optimizes derivation results and whole surgical time without reducing the beneficial effects of the laparoscopic exeresis (AU)

Schwanoma retroperitoneal benigno, exéresis por laparoscopia / Benigne retroperitoneal schwannoma, laparoscopic ressection

Los Schwanomas son tumores raramente localizados en el retroperitoneo, ya que habitualmente se encuentran en nervios craneales o periféricos. Raramente se diagnostican preoperatoriamente ya que ninguna de las técnicas de imagen es capaz de determinarlos con certeza. La RMN parece la prueba de elección. La exéresis quirúrgica completa es el tratamiento estándar. El caso que presentamos corresponde aun schwanoma retroperitoneal benigno como hallazgo a partir de dolor lumbar, en el describimos por primera vez la resección laparoscópica de este tipo de tumors (AU)

Schwannomas are tumors rarely localized in the retroperitoneum, generally appear in craneal as well as periferic nerves. Seldom cases the diagnosis is preoperatively made just because imaging is very poor in this field. MRI is proven to be the diagnostic method. Radical surgical ressection is standarized treatment. We document a case of a benign retroperitoneal schwannoma where we explain the laparoscopic resection of this kind of tumors for first time (AU)

[Laparoscopic radical prostatectomy: learning curve with a mentor training program]. / Prostatectomía radical laparoscópica: la curva de aprendizaje con tutor.

INTRODUCTION: We describe and evaluate the results of our mentor training program for laparoscopic radical Prostatectomy (LRP). MATERIAL AND METHODS: From March 2004 through December 2005, we have performed 105 (LRP). Three groups have been analysed: Group 1: The mentor as the first surgeon with the trainee acting as the assistant. Group 2: The trainee as the first surgeon with the mentor acting as the assistant. Group 3: The trainee as the first surgeon with another trainee/resident as the assistant. We have evaluated operative, postoperative data and surgical/oncological control. RESULTS: There was no statistical difference in mean operative time in Groups 2 and 3 (200'-198'), but there was a difference from Group 1 (148,4') (p<0,05) we have observed a progressive operative time decrease only in Group 1. Blood loss, surgical-oncological control, pathological stage and hospital stay have been similar in the three groups. CONCLUSIONS: Skills for LRP can be effectively and safely taught by the presence of an experienced mentor. Waiting for long term results according to potency and continence, it was not associated to higher patient risk, neither to a worse surgical/oncologic outcome. We consider that this program is reproducible and allows a shorter learning curve.

Fusion esplenogonadal. Presentación de un caso / Splenogonadal fusion. Report of a case

Se presenta un nuevo caso de fusión esplenogonadal en un varón de 27 años. Esta anomalía que resulta la fusión de bazo y gónada a nivel embriológico, se asocia en ocasiones a otras alteraciones congénitas (peromelia). Se presenta con más frecuencia en el escroto izquierdo y aunque descrita en ambos sexos, es diagnosticada con más frecuencia en el sexo masculino. Su importancia clínica radica en que su presentación en forma de tumor suele conducir a la extirpación quirúrgica del mismo. Su reconocimiento a tiempo, (estudio intraoperatorio) puede evitar actuaciones demasiado radicales

We present a new case of splenogonadal fusion in a 27 years old male. This anomaly is the result of an embryological fusion between gonad and spleen. Occasionally there is an association with other congenital alterations (peromelia). Usually it occurs in the left scrotum and, although described in both sexes, it is more frequent in males. Its only symptom is palpable tumor and this makes the surgical approach the only way to make the diagnosis. A frozen section study can avoid unnecessary radical surgery

Prostatectomía radical laparoscópica: la curva de aprendizaje con tutor / Laparoscopic radical prostatectomy: learning curve with a mentor training program

Objetivos: Exponer con detalle el sistema de aprendizaje de la prostatectomía radical laparoscópica (PRL) con tutor llevado a cabo en nuestro centro así como los resultados. Material y métodos: Se realiza el análisis de variables intraquirúrgicas, postoperatorias y del control quirúrgico y oncológico de la pieza, de 105 PRL (marzo 2004-diciembre 2005) según los siguientes grupos: Grupo 1: tutor como primer cirujano y alumno como asistente. Grupo 2 alumno como primer cirujano y el tutor como ayudante. Grupo 3: alumno como primer cirujano y otro alumno/residente como ayudante. Resultados: No se han observado diferencias significativas en cuanto la media de tiempo quirúrgico (TQ) entre el grupo 2 y 3 (188’-170’, p=0,09). Ésta ha sido menor en el Grupo 1 (150’, p<0,05), disminuyendo con el tiempo. La pérdida sanguínea, el control quirúrgico-oncológico, el estadio patológico y el tiempo de estancia hospitalaria han sido similares en los tres grupos. Conclusiones: La presencia de un laparoscopista experto como tutor permite aprender la PRL de manera segura y efectiva. En espera de los resultados funcionales y oncológicos a largo plazo, este sistema de aprendizaje no se asocia ni con un mayor riesgo para el paciente ni con un peor control quirúrgico/oncológico. Consideramos que este método es fácilmente reproducible y permite un acortamiento de la curva de aprendizaje

Material and Methods: From March 2004 through December 2005, we have performed 105 (LRP). Three groups have been analysed: Group 1: The mentor as the first surgeon with the trainee acting as the assistant. Group 2: The trainee as the first surgeon with the mentor acting as the assistant. Group 3: The trainee as the first surgeon with another trainee/resident as the assistant. We have evaluated operative, postoperative data and surgical/oncological control. Results: There was no statistical difference in mean operative time in Groups 2 and 3 (200’-198’), but there was a difference from Group 1 (148,4’) (p<0,05) we have observed a progressive operative time decrease only in Group 1. Blood loss, surgical-oncological control, pathological stage and hospital stay have been similar in the three groups. Conclusions: Skills for LRP can be effectively and safely taught by the presence of an experienced mentor. Waiting for long term results according to potency and continence, it was not associated to higher patient risk, neither to a worse surgical/oncologic outcome. We consider that this program is reproducible and allows a shorter learning curve

Prostatectomía radical laparoscópica versus abierta / Comparison between open and laparoscopic approach in radical prostatectomy

Objetivos. Analizar las diferencias entre la prostatectomía radical abierta (PRA) y la prostatectomía radical laparoscópica (PRL). Material y métodos. Se evalúan 180 cirugías prostáticas radicales realizadas en el 2004 y 2005, de las cuales 105 (58%) fueron laparoscópicas (PRL) y 75 (42%) por vía abierta. Más de la mitad de las intervenciones se realizaron por cirujanos expertos: 51% en las PRL y 56% en las PRA. Se compararon las variables: tiempo quirúrgico, sangrado intraoperatorio (diferencia entre hematocrito prequirúrgico y postquirúrgico) y los días de ingreso. El control oncológico y quirúrgico se evaluaron mediante los parámetros: margen maligno (MM) (margen positivo en un pT3) e incisión quirúrgica benigna (IQB) y maligna (IQM). Resultados. Los dos grupos son comparables respecto a la edad, estadio clínico, Gleason de la biopsia y volumen, sólo difiriendo en el valor de PSA. La media del tiempo quirúrgico fue significativamente mayor en la PRL (172 minutos) versus la PRA (145 minutos). La diferencia del hematocrito fue mayor en la PRA (10,7 puntos) respecto a la PRL (9,2 puntos) (p=0,03), así como los días de ingreso, representando un día más en la PRA (p=0,001). Un 26,7% de las PRL han presentado IQB, frente a un 48,7 % en las PRA (p=0,001). Desde el punto de vista oncológico se han observado un 5,4% de MM en las PRL versus un 16,9% en las PRA. (p=0,023). No obstante, no se han observado diferencias respecto a las IQM. Conclusión. En la PRL, a igualdad de estadio clínico y patológico, se observa un mejor control de los márgenes junto con una menor afectación quirúrgica de la pieza. También existe una menor pérdida sanguínea así como una reducción de los días de ingreso. Por tanto, se puede concluir que la PRL es, en nuestro entorno, una técnica válida para el tratamiento del cáncer de próstata organoconfinado, a pesar de un mayor tiempo quirúrgico (27 minutos) y de la dificultad de su aprendizaje

Introduction. To evaluate the differences between laparoscopic (LRP) and open radical prostatectomy (ORP). Material and Methods. From 2004 to 2005 180 Radical prostatectomies (RP) were performed, 105 laparoscopical and 75 by an open approach. Different urologists have acted as first surgeon; 51% of them, fully experienced ones in OPR, and 56% in LRP. Differences in operative time, estimated blood loss (difference of pre and post operative hematocrite), and duration of hospitalization were compared. Additionally, we have also analysed surgical and oncologic control of the specimen defined by the following variables: Malignant margins (MM) (positive margin in a pT3 specimen), and benign/malign surgical incision (BSI/MSI). Results. Groups were similar concerning age, clinical stage and Gleason score, and there are only differences in PSA. Mean operative time was significantly higher in LRP (172 minutes) versus ORP (145 minutes) (p<0.001). Difference of pre and post operative hematocrite was also higher in the open group (10.7 vs 9,2) (p=0.03), together with hospital stay, which was one day longer in the ORP group (p=0.001). ORP group had a higher rate of benign surgical incisions (48.7% vs 26.7%) (p=0.001). Regarding oncologic results, LRP presented a 5.4 % of positive margins, which compared significantly with a 16.9% rate in the open group (p=0.023). However, no differences concerning malignant surgical incisions were observed. Conclusion. With no differences in clinical and pathological stage, LRP offers a significant reduction of surgical aggressiveness on the specimen, together with a better MM control. We also observe a clear decrease in blood loss and hospital stay. Therefore, we conclude that LRP in our environment is a valid approach of surgical prostate cancer treatment in spite of a longer operative time (27 minutes) and a steep learning curve

[Current status of radical laparoscopic prostatectomy]. / Estado actual de la prostatectomía radical laparoscópica.

Laparoscopic surgery can be said to have come of age when it was first indicated for cancer conditions. Advances in this field are largely due to the French school, which has made it a standard practise in prostate cancer. It complies with the principles required for cancer as well as conventional surgery, but it remains to be verified whether its long-term results, both from tumoral and functional perspectives, are not only similar to those of classical surgery, but even better. In fact, increasing numbers of clinical groups are incorporating this technique in their daily work.

Estado actual de la prostatectomía radical laparoscópica / Current status of radical laparoscopic prostatectomy

La cirugía laparoscópica puede considerarse que ha alcanzado la mayoría de edad al indicarse en la patología oncológica, y debe su desarrollo a las escuelas francesas que sistematizaron su empleo en el cáncer prostático. Cumple los principios que ha de seguir la cirugía oncológica, al igual que la cirugía convencional, pero queda aún por demostrar que los resultados a largo plazo, tanto desde el punto de vista tumoral como el funcional sean mejores que la cirugía clásica. Cada vez son más los grupos que están incorporando estas técnicas a su quehacer diario

Laparoscopic surgery can be said to have come of age when it was first indicated for cancer conditions. Advances in this field are largely due to the French school, which has made it a standard practise in prostate cancer. It complies with the principles required for cancer as well as conventional surgery, but it remains to be verified whether its long-term results, both from tumoral and functional perspectives, are not only similar to those of classical surgery, but even better. In fact, increasing numbers of clinical groups are incorporating this technique in their daily work

Referencia al artículo "Tratamiento quirúrgico del complejo extrofia-epispadias. Revisión y conceptos actuales" / Refer to the article: "Surgical treatment of extrophy-epispadias complex. Review and new concepts"

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[Role of direct radionuclide cystography and renal study by dimercaptosuccinic acid (DMSA) in the diagnosis and follow-up of vesicoureteral reflux]. / La cistografía isotópica directa y la gammagrafía renal con ácido dimercaptosuccínico (DMSA) en el diagnóstico y seguimiento del reflujo vesicoureteral.

AIM: To evaluate the role of isotopic studies in the diagnosis and follow-up of vesicoureteral reflux (VUR) and to present the results of our current protocol. MATERIAL AND METHODS: Forty three patients with VUR were retrospectively studied with a mean follow-up of 43 years (1-11 years). VUR was diagnosed by voiding cystourethrography and followed-up by direct radionuclide cystography. During the follow-up all patients were studied by means of renal DMSA scintigraphy (21 were also studied during the acute phase of febrile urinary tract infection). RESULTS: Eighty three renal units were examined. Voiding cystourethrography was positive for VUR in 49 renal units (59%; 8 grade I, 18 grade II, 15 grade III, and 8 grade IV). During the follow-up, direct radionuclide cystography showed decrease or disappearance of VUR in 29 renal units (35%; 4 grade I, 16 grade II, 7 grade III, and 2 grade IV). DMSA studies performed during the follow-up showed cortical lesions in 17 renal units (5 with VUR grade II, 7 with grade III, and 5 grade IV). Nine of 21 patients examined by DMSA during the acute phase of febrile urinary tract infection showed cortical damage (43%), and 6 of them (67%) progressed to cortical lesion in the follow-up DMSA. CONCLUSIONS: The present protocol allows for the correct diagnosis and control of VUR, the early detection of acute renal damage, and the control of its evolution.

La cistografía isotópica directa y la gammagrafía renal con ácido dimercaptosuccínico (DMSA) en el diagnóstico y seguimiento del reflujo vesicoureteral / Role of direct radionuclide cystography and renal study by dimercaptosuccinic acid (DMSA) in the diagnosis and follow-up of vesicoureteral reflux

Objetivo: Valorar la utilidad de la cistografía isotópica directa (CID) y de la gammagrafía renal con ácido dimercaptosuccínico (DMSA) en el diagnóstico y seguimiento del RVU, según los resultados obtenidos a partir del protocolo actual de nuestro centro. Material y Métodos: Se han estudiado retrospectivamente 43 pacientes diagnosticados de RVU con un período de seguimiento medio de 4 ñ 3 años (1-11 años). El diagnóstico de RVU se realizó mediante cistografía radiológica (CUMS) y el seguimiento mediante CUMS y/o CID. Durante el seguimiento se realizó gammagrafía renal con DMSA a todos los pacientes. Veintiún pacientes también fueron estudiados con DMSA durante la fase aguda de la infección urinaria febril. Resultados: Se exploraron 83 unidades renales. En el momento del diagnóstico la CUMS fue positiva para RVU en 49 unidades renales (59 per cent; 8 grado I, 18 grado II, 15 grado III y 8 grado IV). Durante el seguimiento por CID se observó disminución o desaparición del RVU en 29 unidades renales (35 per cent; 4 grado I, 16 grado II, 7 grado III y 2 grado IV). Durante el seguimiento el DMSA mostró lesiones corticales en 17 unidades renales (5 con RVU grado II, 7 grado III y 5 grado IV). Nueve de los 21 pacientes estudiados con DMSA durante la fase aguda de la infección urinaria febril presentaron afectación cortical (43 per cent), de los cuales 6 evolucionaron a lesión cortical en el DMSA de control (67 per cent). Conclusiones: El protocolo descrito permite diagnosticar y controlar el RVU, identificar precozmente la afectación renal y controlar su evolución (AU)

[Management of acute prostatitis: experience with 84 patients]. / Manejo de las prostatitis agudas: experiencia en 84 pacientes.

OBJECTIVES: The present study analyzed the symptoms, etiology, utility of complementary diagnostic procedures, treatment and subsequent course of patients with acute prostatitis in our setting. METHODS: We reviewed the clinical records of patients admitted to our department from 1988 to 1992 with the diagnosis of acute prostatitis. The present study comprised 84 patients for a total of 114 cases including reinfections. RESULTS: Acute prostatitis with irritative voiding symptoms was observed in 81% of the cases and was associated with fever (60%), pain (38%), systemic involvement (23%), urinary obstructive symptoms (11.5%) and hematuria (11%). It is more prevalent in middle aged men (mean 53 years); reinfection and persistence of infection are not uncommon (18% and 21%, respectively). A painful (72%) and enlarged (87%) prostate are the most important features and are detected by digital rectal examination (DRE). Leukocytosis with a left shift can also be observed. The most common pathogen in the first episode and subsequent reinfections was E. coli (64%), followed by abacterial (12%), enterococcus (7%), Pseudomonas (6%) and other gram-negative rods (12%). The antibiotic profile showed a sensitivity greater than 95% to imipenem, aminoglycosides, most of the cephalosporins and ciprofloxacin, and 83% sensitivity to trimethoprim-sulfamethoxazole. Ultrasonography did not provide more information than that already obtained from the symptoms and DRE. No correlation was found with previous urologic history or subsequent course of the disease. CONCLUSIONS: Acute prostatitis is an infection with a tendency to persist or recur. To avoid the persistence or recurrence of this condition, an accurate diagnosis must be made based on the symptoms and DRE findings, early and prolonged therapy is required, as well as subsequent follow up with Stamey's test, semen and urine analyses.