Incidence of Bladder Cancer in Patients Undergoing Radiotherapy for Prostate Cancer.

INTRODUCTION: Radiotherapeutic treatment of prostate cancer has been validated in terms of efficacy, but its relationship with the occurrence of second pelvic primary malignancy and the relevance of radio-induced toxicity is still under debate. This study analyses the occurrence of second pelvic primary malignancy as well as morbidity secondary to radiotherapy treatment in patients treated for prostate cancer. MATERIAL AND METHODS: Retrospective consecutive descriptive study of 317 patients who received radiotherapy treatment for prostate cancer between 2007 and 2017. Predictor variables, side effects and the appearance of second pelvic primary malignancy during a maximum follow-up of 10 years were collected. We analyse whether there is a significant relationship in the appearance of second pelvic primary malignancy and describe the clinical toxicity presented by the patients. RESULTS: The median age was 62.27 years and the most commonly employed treatment modality was brachytherapy with IMRT (60%). 17 patients (5.4%) developed a second pelvic primary malignancy, with a median time to onset of 58 and 25 months for bladder and colon tumours, respectively. Local recurrence and mortality rates are 8% and 7%, respectively. Statistically significant association is demonstrated for the occurrence of second pelvic primary malignancy and for chronic radioinduced toxicity according to type of radiotherapy χ2 (4) = 16.34; p = 0.003 and χ2 (1) = 6.47; p = 0.011 respectively. CONCLUSIONS: In our series, the occurrence of a second pelvic primary malignancy is statistically associated with the modality of radiotherapy administered and occurrence of chronic adverse effects.

Incidence of Bladder Cancer in Patients Undergoing Radiotherapy for Prostate Cancer

Introduction: Radiotherapeutic treatment of prostate cancer has been validated in terms of efficacy, but its relationship with the occurrence of second pelvic primary malignancy and the relevance of radio-induced toxicity is still under debate. This study analyses the occurrence of second pelvic primary malignancy as well as morbidity secondary to radiotherapy treatment in patients treated for prostate cancer. Material and Methods: Retrospective consecutive descriptive study of 317 patients who received radiotherapy treatment for prostate cancer between 2007 and 2017. Predictor variables, side effects and the appearance of second pelvic primary malignancy during a maximum follow-up of 10 years were collected. We analyse whether there is a significant relationship in the appearance of second pelvic primary malignancy and describe the clinical toxicity presented by the patients. Results: The median age was 62.27 years and the most commonly employed treatment modality was brachytherapy with IMRT (60%). 17 patients (5.4%) developed a second pelvic primary malignancy, with a median time to onset of 58 and 25 months for bladder and colon tumours, respectively. Local recurrence and mortality rates are 8% and 7%, respectively. Statistically significant association is demonstrated for the occurrence of second pelvic primary malignancy and for chronic radioinduced toxicity according to type of radiotherapy χ2 (4) = 16.34; p = 0.003 and χ2 (1) = 6.47; p = 0.011 respectively. Conclusions: In our series, the occurrence of a second pelvic primary malignancy is statistically associated with the modality of radiotherapy administered and occurrence of chronic adverse effects (AU)

The 3-day bladder diary is a feasible, reliable and valid tool to evaluate the lower urinary tract symptoms in women.

AIMS: To evaluate the feasibility (% of completion), reliability (test-retest and inter-observer) and validity (convergent vs. questionnaires and vs. urodynamic study-UDS) of the 3-day bladder diary (3dBD) in women with lower urinary tract symptoms (LUTS). METHODS: Epidemiological, descriptive, cross-sectional and prospective study. Fourteen Functional Urology and Urodynamic Units participated. One hundred thirty-six women with mean age (SD) 55.2 (13.8) years with LUTS, without bladder catheterization and who were able to fill in the 3dBD were included. An UDS was performed. They filled in the 3dBD in two times separated by 15 days (test and retest), the International Consultation on Incontinence-Short Form (ICIQ-UI SF) and the Bladder Control Self-Assessment Questionnaire (BSAQ). RESULTS: One hundred ten women completed 3dBD for test and retest. Feasibility: each 3dBD has 42 variables, 77.2% women completed 80%. Test-retest reliability: there were not differences in the proportion of patients classified as positive for each symptom (urgency: P = 0.3173; incontinence: P = 1; nocturia: P = 0.0522; frequency: P = 0.4386). The Intraclass Correlation Coefficient (ICC) ranged from 0.67 to 0.92, except for night time VVmax which was lower (0.54). Inter-observer reliability: ICC ranged from 0.64 to 0.99, except for day time VVmax (0.29) and the number of urgency episodes (0.45). VALIDITY: Spearman correlation coefficients for ICIQ-UI SF and BSAQ ranged from 0.4 to 0.6 (P < 0.0001) and for UDS were lower (P < 0.05). CONCLUSIONS: The 3dBD showed good feasibility, reliability and validity to be used in the assessment of LUTS in women.

Disfunción miccional en el cáncer de próstata / Voiding dysfunction in prostate cancer

OBJETIVO: El cáncer prostático es la neoplasia urológica que ha experimentado más cambios en la última década, habiéndose demostrado un gran aumento en su incidencia y en su diagnóstico. El manejo de los pacientes con cáncer de próstata es evidentemente multidisciplinar, participan principalmente Urólogos, pero también Anatomopatólogos especializados, Radiólogos, Bioquímicos, Oncólogos Médicos y Radioterapeutas y otros.La larga supervivencia esperada generalmente en ellos, hace que no sea sostenible la rutinaria visita de control con PSA, no prestando la debida atención a la presencia de síntomas urinarios, amén de otros trastornos funcionales cuya repercusión afecta en gran medida a su calidad de vida.Pretendemos incidir en la disfunción miccional que acompaña a pacientes con cáncer de próstata, desde un punto de vista no oncológico y sí urodinámico y de calidad de vida. Secundariamente plantear los aspectos clínicos no trasladados a patología funcional y urodinámica (toxicidad urinaria, toxicidad radioinducida, hiperactividad vesical…)MÉTODOS: Revisión y puesta al día de la disfunción miccional que puede acompañar al cáncer de próstata. No solo de la incontinencia post-prostatectomía radical. Se integra la experiencia del autor en su fisiopatología, electromiografía esfinteriana y urodinámica, así como de la revisión general del tema según la bibliografía más actual.RESULTADOS: Se ha mejorado mucho la técnica quirúrgica, proporcionando resultados de continencia muy altos, sin poderse plantear que una vía de abordaje o el empleo del robot sea superior a las demás.Son múltiples las situaciones urodinámicas que nos presenta el cáncer de próstata. Obstrucción del tracto urinario inferior, compresiva o constrictiva, hiperactividad del detrusor, acomodación disminuida, incontinencia urinaria de esfuerzo por déficit esfinteriano, incontinencia urinaria mixta, desfuncionalización vesical. Otras situaciones no están definidas por la urodinámica(AU)

CONCLUSIONES: Los pacientes con cáncer de próstata pueden tener actualmente una evaluación deficiente de la calidad de vida por parte del urólogo respecto a sus síntomas urinarios por prevalecer los aspectos oncológicos en su evaluación.El cáncer de próstata muestra una gran diversidad de situaciones urodinámicas objeto de estudio, no solo la incontinencia post-prostatectomía radical(AU)

OBJECTIVES: Prostate cancer is the urologic neoplasia that has experienced more changes in the last decade, with a great increase in incidence and diagnosis. Prostate cancer patient’s management is clearly multidisciplinary, with the participation of urologists mainly, but also specialized pathologists, radiologists, biochemists, medical oncologists, radiation oncologists and others.The expected long survival makes the routine visit for PSA control non sustainable, without paying attention to the presence of urinary symptoms and other functional disorders with great repercussion on the quality of life.OBJECTIVES: To present urinary dysfunction in patients with prostate cancer from a non oncological but urodynamic and quality of life point of view. Secondarily, to pose the clinical features not translated to functional and urodynamic pathology (urinary toxicity, radiation toxicity, bladder hyperactivity…)METHODS: We review and update voiding dysfunction that may be present in prostate cancer patients. Not only urinary incontinence after radical prostatectomy. We integrated author`s experience with its physiopathology, sphincter electromyography, and urodynamics, and a general review on the topic using the latest bibliography.RESULTS: Surgical techniques have improved very much, resulting in very high continence rates, which do not enable to consider one approach or the use of robotics better than others.Prostate cancer present multiple urodynamic scenarios. Constrictive or compressive lower urinary tract obstruction, detrusor muscle hyperactivity, diminished compliance, stress urinary incontinence due to sphincteric deficit, mixed urinary incontinence, bladder dysfunction. Other scenarios are not defined by urodynamics(AU)

CONCLUSIONS: Patients with prostate cancer may currently receive a defective evaluation by their urologists in terms of urinary symptoms due to the prevalence of oncological features in their evaluation.Prostate cancer shows a great diversity of urodynamic scenarios subject of study, not only post-radical prostatectomy incontinence(AU)

Incontinencia urinaria tras prostatectomía radical: Evolución histórica de la técnica quirúrgica y estado actual del resultado funcional / Urinary incontinence after radical prostatectomy: Surgical technique historic evolution and present functional outcomes

OBJETIVO: La prostatectomía radical (PR) es el tratamiento de elección en los pacientes con cáncer de próstata organoconfinado y una esperanza de vida mayor de 10 años. La cirugía radical de la próstata debe incluir unos buenos resultados oncológicos y funcionales, con un mantenimiento precoz de la continencia y potencia sexual postquirúrgicas. En manos expertas la PR ofrece muy bajas tasas de incontinencia urinaria postprostatectomia.Analizar la evolución y los resultados funcionales en cuanto a la incontinencia urinaria (IU) tras PR que tenemos en nuestro centro en los últimos diez años.MÉTODOS: Hemos realizado un estudio retrospectivo de los 137 pacientes sometidos a prostatectomía radical (retropúbica y laparoscópica) en el Hospital General Universitario de Elche, en el período comprendido entre 1998 y 2008. Se analizaron dos grupos de pacientes, los intervenidos de 1998-2003 y aquellos que se operaron del 2004-2008, ambos inclusive. En ambos grupos se determinó el porcentaje de IU de esfuerzo tras PR, mediante el número de compresas utilizadas al día por cada paciente, al mes, 3 meses, 6 meses y al año de la cirugía. También se analizaron el número de estenosis de la anastomosis uretrovesical en cada grupo y cómo se resolvieron(AU)

RESULTADOS: De los 137 pacientes iniciales, se excluyeron 15 de ellos por tratarse de estadios cT3, resultando el total en 122 prostatectomías con estadio < cT2c.La edad media de los pacientes fue de 67 años (50-74). La media del PSA preoperatorio fue de 8,1 ng/ml (4,5 -25). El Gleason en la biopsia fue < de 6 en el 70 % (85/122) y de 7-8 en el 30 % (37/122). En el periodo comprendido entre 1998-2003 se intervinieron 49 pacientes y se obtuvieron los siguientes resultados: Continentes de inicio: 28,5 % (14/49), continentes al mes: 6,1 % (3/49), continentes a los 3 meses: 12,2 % (6/49), continentes a los 6 meses: 8,1 % (4/49), continentes al año: 22,4 % (11/49). Quedaron con IU leve el 20,4 % (10/49) y con IU moderada/severa el 2 % (1/49). En este periodo el 78 % de los pacientes resultaron continentes y el 22 % incontinentes.En el periodo de 2004-2008 se realizaron 73 prostatectomías radicales con las siguientes tasas de continencia: Continentes de inicio: 44 % (32/73), continentes al mes: 0 pacientes, continentes a los 3 meses: 6,8 % (5/73), continentes a los 6 meses: 12,3 % (9/73), continentes al año: 24,6 % (18/73). Quedaron con IU leve el 8,2 % (6/73) y con IU moderada/severa el 4 %(AU)

(3/73). Resultaron continentes un total del 88 % de los pacientes e incontinentes el 12 %.CONCLUSIONES: La incontinencia urinaria es un trastorno poco frecuente en los pacientes sometidos a PR por cáncer de próstata. Las tasas de continencia han ido mejorando en los últimos años con la mejora de la técnica quirúrgica y con la experiencia del urológo. Por este motivo, los dispositivos antiincontinencia tras PR son necesarios en contadas ocasiones y su uso está sobredimensionado.Palabras clave: Cáncer próstata. Prostatectomía. Incontinencia urinaria.Summary.- OBJECTIVES: In patients with localized prostate cancer and life expectancy longer than 10 years, radical prostatectomy (RP) remains the Gold Standard. Radical surgery must achieve good oncological and functional outcomes with early continence and potency. In expert hands RP offers very low post-prostatectomy urinary incontinence rates.To analyze functional outcomes regarding urinary incontinence (UI) after RP in our centre in the last ten years.METHODS: We have performed a retrospective study of the 137 patients who had a radical prostatectomy (open retropubic or laparoscopic) on the General University Hospital of Elche from 1998 to 2008. Two patient groups were analyzed, patients who had surgery from 1998 to 2003, and those who had surgery from 2004 to 2008. Stress UI rates after RP were determined in both groups at 1, 3, 6 and 12 months following surgery with patient pad day usage. Urethrovesical anastomosis strictures were also analyzed in each group and their resolution(AU)

RESULTS: 15 patients were excluded from the initial 137 because cT3 stage was detected, remaining 122 prostatectomies with

[Voiding dysfunction in prostate cancer]. / Disfunción miccional en el cáncer de próstata.

OBJECTIVES: Prostate cancer is the urologic neoplasia that has experienced more changes in the last decade, with a great increase in incidence and diagnosis. Prostate cancer patient's management is clearly multidisciplinary, with the participation of urologists mainly, but also specialized pathologists, radiologists, biochemists, medical oncologists, radiation oncologists and others. The expected long survival makes the routine visit for PSA control non sustainable, without paying attention to the presence of urinary symptoms and other functional disorders with great repercussion on the quality of life. OBJECTIVES: To present urinary dysfunction in patients with prostate cancer from a non oncological but urodynamic and quality of life point of view. Secondarily, to pose the clinical features not translated to functional and urodynamic pathology (urinary toxicity, radiation toxicity, bladder hyperactivity...) METHODS: We review and update voiding dysfunction that may be present in prostate cancer patients. Not only urinary incontinence after radical prostatectomy. We integrated author;s experience with its physiopathology, sphincter electromyography, and urodynamics, and a general review on the topic using the latest bibliography. RESULTS: Surgical techniques have improved very much, resulting in very high continence rates, which do not enable to consider one approach or the use of robotics better than others. Prostate cancer present multiple urodynamic scenarios. Constrictive or compressive lower urinary tract obstruction, detrusor muscle hyperactivity, diminished compliance, stress urinary incontinence due to sphincteric deficit, mixed urinary incontinence, bladder dysfunction. Other scenarios are not defined by urodynamics. CONCLUSIONS: Patients with prostate cancer may currently receive a defective evaluation by their urologists in terms of urinary symptoms due to the prevalence of oncological features in their evaluation. Prostate cancer shows a great diversity of urodynamic scenarios subject of study, not only post-radical prostatectomy incontinence.

[Urinary incontinence after radical prostatectomy: surgical technique historic evolution and present functional outcomes]. / Incontinencia urinaria tras prostatectomía radical: evolución histórica de la técnica quirúrgica y estado actual del resultado funcional.

OBJECTIVES: In patients with localized prostate cancer and life expectancy longer than 10 years, radical prostatectomy (RP) remains the Gold Standard. Radical surgery must achieve good oncological and functional outcomes with early continence and potency. In expert hands RP offers very low post-prostatectomy urinary incontinence rates. To analyze functional outcomes regarding urinary incontinence (UI) after RP in our centre in the last ten years. METHODS: We have performed a retrospective study of the 137 patients who had a radical prostatectomy (open retropubic or laparoscopic) on the General University Hospital of Elche from 1998 to 2008. Two patient groups were analyzed, patients who had surgery from 1998 to 2003, and those who had surgery from 2004 to 2008. Stress UI rates after RP were determined in both groups at 1, 3, 6 and 12 months following surgery with patient pad day usage. Urethrovesical anastomosis strictures were also analyzed in each group and their resolution. RESULTS: 15 patients were excluded from the initial 137 because cT3 stage was detected, remaining 122 prostatectomies with

Transvaginal adjustable tape: an adjustable mesh for surgical treatment of female stress urinary incontinence.

After transvaginal adjustable tape, approximately 15% of patients still suffer incontinence, and voiding dysfunction is present in a relatively important number of patients. Transvaginal adjustable tape (TVA) permits postoperative readjustment of tension, suggesting that better results could be obtained. Sixty-four incontinent women received TVA. Patients were monitored 1, 6, and 12 months post-surgery and annually thereafter by medical history, cough stress test, flowmetry and post-void residual test (PVR), incontinence quality of life, International Consultation on Incontinence Questionnaire-Short Form, and Patient Global Impressions of Improvement (PGI-I) questionnaires. After adjustment, all patients rendered continent, and none had PVR. On no occasion was vesical catheterization or uretholysis necessary. Mean follow-up was 40+/-12.9 months. Objective and subjective cure rate were 94% and 56%, respectively. Qmax was 22.3+/-9.9 ml/s. The PGI-I questionnaire showed 94% of patients to be better or very much better than before. Our data suggest that with TVA tape, better results can be obtained, furthermore, without increasing surgical complications.

[Secondary bladder amyloidosis with severe recurrent hematuria: transurethral Mickuliz procedure as hemostatic option]. / Hematuria grave recidivante por amiloidosis vesical secundaria. Mikulicz transuretral como opción hemostática.

OBJECTIVES: Primary localized amyloidosis of the urinary bladder generally has a benign course. On the contrary, secondary amyloidosis, a consequence of systemic amyloidosis, may have massive bleeding and produce complications such as bladder rupture or life-threatening hemodynamic problems requiring desperate hemostatic procedures such as hypogastric artery embolization or ligature, or cystectomy. We report one case in which hemostasis was achieved by a Mickulicz transurethral bladder tamponage. METHODS: 58 year old female with very aggressive rheumatoid arthritis and secondary renal amyloidosis under chronic hemodialysis presenting with severe hematuria after hip replacement. An inflamed bladder was found, the biopsy of which showed edema in all layers with blood vessel walls enlarged by amiloyd deposits. After several unsuccessful transurethral hemostatic procedures, intravesical formalin irrigation was carried out together with a Mikulicz type gauze packaging after urethral dilation. The gauze was withdrawn three days later without bleeding recurrence; however she presented subsequent neurological impairment and finally died 14 days after the last urological procedure. CONCLUSIONS: Transurethral packaging of the urinary bladder in a woman with massive hematuria is a hemostatic option that we recommend to be used before other more dramatic or invasive options are chosen.

Hematuria grave recidivante por amiloidosis vesical secundaria. Mikulicz transuretral como opción hemostática / Secondary bladder amyloidosis with severe recurrent hematuria: transurethral Mickuliz procedure as hemostatic option

OBJETIVO: Al contrario que la amiloidosisvesical primaria o localizada, cuyo curso es generalmentebenigno, en la forma secundaria, consecuenciade amiloidosis sistémica, el sangrado puede sermasivo, con necesidad de procedimientos hemostáticosdesesperados como la ligadura de las arterias hipogástricaso la cistectomía. Describimos un caso en elque la hemostasia se logró mediante un taponamientovesical transuretral de tipo Mikulicz.MÉTODO Y RESULTADO: Una mujer de 58 años conartritis reumatoide muy agresiva, amiloidosis renalsecundaria y en hemodiálisis crónica, presentabahematuria grave después de haber sido operada de lacadera . Se le encontró una vejiga inflamatoria en cuyabiopsia, todas las capas estaban edematizadas y lasparedes de los vasos engrosadas por depósitos deamiloide. Después de varios procedimientos hemostáticostransuretrales infructuosos, se realizó una formolización vesical, y un taponamiento endovesical de tipoMikulicz con vendas de gasa introducidas a través dela uretra previamente dilatada. La gasa exteriorizadapor uretra pudo retirarse al tercer dia, sin que reaparecierala hematuria, aunque tuvo un posterior deterioroneurológico, falleciendo finalmente a los catorcedías de la última intervención.CONCLUSIÓN: El taponamiento vesical transuretral enuna mujer con hematuria intensa es una opción hemostáticaque recomendamos probar antes de elegir otrasmás dramáticas o invasivas

OBJECTIVES: Primary localized amyloidosis ;;of the urinary bladder generally has a benign course. ;;On the contrary, secondary amyloidosis, a consequence ;;of systemic amyloidosis, may have massive bleeding ;;and produce complications such as bladder rupture or ;;life-threatening hemodynamic problems requiring desperate ;;hemostatic procedures such as hypogastric artery ;;embolization or ligature, or cystectomy. We report one ;;case in which hemostasis was achieved by a Mickulicz ;;transurethral bladder tamponage. ;;METHODS: 58 year old female with very aggressive ;;rheumatoid arthritis and secondary renal amyloidosis ;;under chronic hemodialysis presenting with severe ;;hematuria after hip replacement. An inflamed bladder ;;was found, the biopsy of which showed edema in all ;;layers with blood vessel walls enlarged by amiloyd ;;deposits. After several unsuccessful transurethral hemostatic ;;procedures, intravesical formalin irrigation was carried ;;out together with a Mikulicz type gauze packaging after ;;urethral dilation. The gauze was withdrawn three days ;;later without bleeding recurrence; however she presented ;;subsequent neurological impairment and finally died 14 ;;days after the last urological procedure. ;;CONCLUSIONS: Transurethral packaging of the urinary ;;bladder in a woman with massive hematuria is a ;;hemostatic option that we recommend to be used before ;;other more dramatic or invasive options are chosenOBJECTIVES: Primary localized amyloidosis ;;of the urinary bladder generally has a benign course. ;;On the contrary, secondary amyloidosis, a consequence ;;of systemic amyloidosis, may have massive bleeding ;;and produce complications such as bladder rupture or ;;life-threatening hemodynamic problems requiring desperate ;;hemostatic procedures such as hypogastric artery ;;embolization or ligature, or cystectomy. We report one ;;case in which hemostasis was achieved by a Mickulicz ;;transurethral bladder tamponage. ;;METHODS: 58 year old female with very aggressive ;;rheumatoid arthritis and secondary renal amyloidosis ;;under chronic hemodialysis presenting with severe ;;hematuria after hip replacement. An inflamed bladder ;;was found, the biopsy of which showed edema in all ;;layers with blood vessel walls enlarged by amiloyd ;;deposits. After several unsuccessful transurethral hemostatic ;;procedures, intravesical formalin irrigation was carried ;;out together with a Mikulicz type gauze packaging after ;;urethral dilation. The gauze was withdrawn three days ;;later without bleeding recurrence; however she presented ;;subsequent neurological impairment and finally died 14 ;;days after the last urological procedure. ;;CONCLUSIONS: Transurethral packaging of the urinary ;;bladder in a woman with massive hematuria is a ;;hemostatic option that we recommend to be used before ;;other more dramatic or invasive options are chosen

[Surgical treatment of female urethral diverticula. Our experience. Bibliographic review]. / Tratamiento quirúrgico del divertículo uretral femenino. Nuestra experiencia. Revisión de la literatura.

OBJECTIVES: Female urethral divertilum is a rare disease; its diagnosis has increased with the use of new diagnostic technologies. It must be suspected in women consulting for chronic irritative symptoms without response to conventional treatments. Transvaginal surgical excision is the most accepted therapeutic option. We reviewed their clinical presentations, diagnostic findings, and therapeutic options and report our experience. METHODS/RESULTS: We retrospectively reviewed our case series, finding 4 patients with the diagnosis of female urethral diverticulum; we performed a bibliographic review. CONCLUSIONS: Urethral diverticulum is a rare clinical entity which has to be included in the differential diagnosis of women with chronic lower urinary tract symptoms. Clinical presentation may vary from asymptomatic to rich voiding symptoms. The most frequently used diagnostic method is voiding cystourethrogram; other techniques such as transvaginal ultrasound or MRI are very useful for complicated cases. Surgical treatment by transvaginal diverticulectomy with closure in several layers is the most frequent approach. Postoperative complications are rare.

Tratamiento quirúrgico del divertículo uretral femenino. Nuestra experiencia. Revisión de la literatura / Surgical treatment of female urethral diverticula. Our experience. Bibliographic review

OBJETIVO: El divertículo uretral femeninoes una patología de baja frecuencia y cuyo diagnósticose ha visto incrementado por el uso de nuevas técnicasdiagnósticas. Debe sospecharse ante mujeresque acuden a la consulta con sintomatología crónicairritativa sin respuesta a tratamientos convencionales. Laopción terapéutica más aceptada es la escisión transvaginaldel mismo. Revisamos su presentación clínica,aspectos diagnósticos y opciones terapéuticas presentandonuestra experiencia.MÉTODOS/RESULTADOS: Hemos realizado un estudioretrospectivo de nuestra casuística, localizando 4enfermas diagnosticadas de divertículo uretral femeninoy revisada la literatura científica al respecto.CONCLUSIONES: El divertículo uretral es una entidadclínica infrecuente que hay que tener en cuenta en todamujer con sintomatología crónica del tracto urinarioinferior. Su forma de presentación puede ser desdeasintomática hasta sintomatología miccional florida. Elmétodo diagnóstico más usado es la cistouretrografíamiccional, aceptando la gran utilidad de técnicascomo la ecografía transvaginal o la resonancia magnéticanuclear en casos complejos. El tratamiento quirúrgicomediante diverticulectomía transvaginal con cierreen varios planos es el abordaje más empleado. Lascomplicaciones postoperatorias son escasas

OBJECTIVES: Female urethral divertilumis a rare disease; its diagnosis has increased with theuse of new diagnostic technologies. It must be suspectedin women consulting for chronic irritative symptomswithout response to conventional treatments.Transvaginal surgical excision is the most acceptedtherapeutic option. We reviewed their clinical presentations,diagnostic findings, and therapeutic options and reportour experience.METHODS/RESULTS: We retrospectively reviewed ourcase series, finding 4 patients with the diagnosis offemale urethral diverticulum; we performed a bibliographicreview.CONCLUSIONS: Urethral diverticulum is a rare clinicalentity which has to be included in the differential diagnosisof women with chronic lower urinary tract symptoms.Clinical presentation may vary from asymptomatic torich voiding symptoms. The most frequently useddiagnostic method is voiding cystourethrogram; othertechniques such as transvaginal ultrasound or MRI arevery useful for complicated cases. Surgical treatment bytransvaginal diverticulectomy with closure in severallayers is the most frequent approach. Postoperativecomplications are rare

El sling de malla de prolene en el tratamiento de la incontinencia urinaria de esfuerzo. Tratamiento integral de las alteraciones del suelo pélvico. Resultados a largo plazo / The prolene mesh sling in the treatment of urinary stress incontinence. Comprehensive treatment of pelvic floor disorders. Long term results

OBJETIVOS: Evaluar los resultados del tratamiento integral de la incontinencia urinaria de esfuerzo femenina, con sling de malla de prolene, asociando en el mismo acto quirúrgico la reparación ginecológica oportuna, según el tipo de disfunción perineal y prolapso. Analizar resultados clínicos, urodinámicos a corto y largo plazo, la repercusión sobre la calidad de vida y trascendencia económica de la incontinencia urinaria femenina. MÉTODO: Estudio prospectivo de 102 mujeres consecutivas, con incontinencia urinaria, iniciado en junio de 1996, cerrado en este análisis en Marzo de 2002, que prosigue en la actualidad. En todos los casos se recogieron antecedentes neurourológicos, radioterapia, oncológicos, ginecológicos y cirugías previas por incontinencia. Se realizó historia clínica, evaluando clínica miccional, tiempo de evolución de la incontinencia, y exploración física dirigida a los síntomas urinarios: in continencia, urgencia, urgencia-incontinencia, así como exploración ginecológica con valoración de cistocele, rectocele, prolapso, enterocele, y prolapso de bóveda según grados. Estudio urodinámico completo previo y postcirugía. Se indicó cirugía como procedimiento integral de reparación de la disfunción perineal en todos los casos con incontinencia urinaria de esfuerzo, con la realización de sling con malla de prolene, histerectomía según prolapso, colpoperinerorrafia anterior, con o sin malla y posterior. Se evaluaron los resultados referidos a continencia urinaria, complicaciones, tratamiento de las mismas, en postoperatorio al alta, a los 6 meses y control anual que prosigue en la actualidad. RESULTADOS: La media de edad es de 63,8 años (2782 años, sd 11,2). El 39,3 por ciento de la muestra tiene una edad superior a los 70 años. La media de seguimiento es de 4,25 años (12-75 meses, sd 11,9). La incontinencia urinaria ha costado a cada enferma 2741,17 Euros (456.117 pesetas) en compresas. En el 32,3 por ciento de los casos existen factores de riesgo de fracaso para el tratamiento quirúrgico de la incontinencia urinaria y en el 18,8 por ciento de los casos la presión abdominal de fuga es inferior a 30 cm de agua. Inestabilidad vesical demostrada previamente se presentó en el 22,3 por ciento de los casos. Se practicaron 102 sling, 20 histerectomías, 26 plastias anteriores, 14 plastias posteriores, 10 mallas para reparación de cistocele, una malla posterior, dos promontopexias con malla para enterocele, lo que suponen 173 procedimientos quirúrgicos en 102 anestesias. Fueron necesarias 9 anestesias adicionales para tratamiento de complicaciones. Se ha conseguido continencia al esfuerzo hasta la fecha en el 99,01 por ciento de los casos a este seguimiento. Incontinencia de urgencia se presenta en el plazo del primer año de la cirugía en la mitad de las enfermas que la refieren previamente. La inestabilidad vesical postoperatoria la presentan 11 casos, de los cuales 7 la presentan previamente y de novo aparece en 4 casos. Complicaciones: Por exceso de tensión del sling, 5 casos precisaron sección-recomposición. Por defecto de tensión (sling inefectivo); 3 casos que precisaron tensión o recomposición. En 2 casos perforación vesical accidental tratada con cierre y derivación urinaria. En 1 caso infección- absceso en punto izdo de anclaje de malla, drenaje simple bajo anestesia local. Dolor suprapúbico, inguinal y rectal en 6 casos (8,1 por ciento), en todos ellos desparecido a los 9 meses. En 2 casos infección de herida. CONCLUSIONES: Se ha conseguido curación a largo plazo de la incontinencia urinaria de esfuerzo mediante el sling con malla de prolene en prácticamente todos los casos (99,01 por ciento), incluyendo casos complejos. En un único procedimiento quirúrgico en el 91,1 por ciento, precisando procedimientos adicionales el 8,8 por ciento. Los resultados han sido perdurables en el tiempo en un seguimiento clínicouro dinámico de 4,25 años. La urgencia miccional referida en el 81 por ciento de mujeres con grandes prolapsos, se asocia a inestabilidad vesical demostrada en el 63 por ciento de los casos. Tanto la urgencia miccional como la inestabilidad vesical desaparece en todos los casos a excepción de uno, siendo este dato dependiente de la corrección de dicho prolapso, por ello, la corrección oportuna del prolapso pélvico juega un papel decisivo. La inestabilidad vesical de novo es muy poco frecuente (3,9 por ciento) y de aparición azarosa en esta serie (AU)

Obstrucción tras cirugía correctora de la incontinencia femenina de esfuerzo. Diagnóstico y tratamiento / Obstruction after female stress urinary incontinence corrective surgery. Diagnosis and treatment

OBJETIVO: El objetivo de este estudio es presentar nuestra experiencia en el diagnóstico y tratamiento de la obstrucción del tracto urinario inferior secundaria a cirugía anti-incontinencia, analizando las diferentes técnicas quirúrgicas realizadas, uretrolisis retropubiana o vaginal. MÉTODO: Presentamos una serie de 14 enfermas diagnosticadas de obstrucción tras cirugía antincontinencia. Se clasifican en dos grupos, las intervenidas con técnicas retropúbicas (5 casos) y a las que se practicó sling con malla de prolene (9 casos). Se detallan parámetros clínico-urodinámicos previos a dicha cirugía, y la confirmación de obstrucción del tracto urinario inferior post-cirugía antincontinencia. Se practicó uretrolisis retropúbica en todas las enfermas con antecedentes de cirugía retropubiana, asociando histerectomía si indicada. Se individualizó la realización de nueva resuspensión-sling. No se realizó resuspensión en tres casos . En los casos con sling se practicó sección del sling en una rama y en uno de los casos en ambas ramas. En dos casos se construyó un nuevo sling con malla, y dos casos no fueron intervenidos. Se valoró el resultado de la uretrolisis subjetivamente mediante escala de grado de satisfacción y objetivamente mediante evaluación clínico-urodinámica, comparando los datos clínicos y los parámetros del estudio urodinámico completo, con el correspondiente estudio estadístico. RESULTADOS: En el grupo de cirugía retropúbica todas las pacientes son continentes. El grado de satisfacción es: muy satisfechas 3 pacientes y 2 bastante satisfechas. Dos presentan urgencia miccional sin precisar anticolinérgicos, y los datos urodinámicos retornan a los valores normales sin residuo postmiccional. Las enfermas obstruidas por sling, tras la uretrolisis refieren en dos casos mínima urgencia miccional. Dos casos presentan incontinencia de esfuerzo, una de ellas, se encuentra mejor que previamente y no quiere una tercera cirugía; la otra, intervenida con nuevo sling, desarrolló un nuevo cuadro de urgencia-incontinencia, segunda sección y persiste incontinencia de esfuerzo. De las siete pacientes intervenidas, 4 están muy satisfechas, 1 bastante satisfecha, 1 ligeramente satisfecha y otra nada satisfecha. La dificultad miccional ha desaparecido en todos los casos y la comparación de los parámetros urodinámicos pre y post-uretrolisis demostraron que el flujo miccional máximo, presión del detrusora flujo máximo y residuo postmiccional tienen diferencias estadísticamente significativas. Los valores post-uretrolisis retornan a los valores pre-cirugía de incontinencia. CONCLUSIONES: La relación temporal inmediata clara entre la intervención antiincontinencia y la parición de la sintomatología es el mejor criterio diagnóstico de la obstrucción tras dicha cirugía. El detrusor responde a la obstrucción, pero la respuesta es, a veces, tan mínima, que hace difícil el diagnóstico urodinámico. El conocimiento de los valores previos a la cirugía ayuda a confirmar el diagnóstico. En cualquier caso, los parametros urodinámicos no han influido en el éxito de la uretrolisis. La uretrolisis es una técnica efectiva en conseguir la desaparición de la sintomatología producida tras la obstrucción por cirugía antiincontinencia. Cuando la técnica realizada ha sido un sling, posiblemente no merezca la pena realizar una uretrolisis reglada, la simple sección de una de las ramas del sling parece ser suficiente para mejorar la clínica. No existe en estos momentos seguridad científica sobre la conveniencia o no de resuspensión cervicouretral tras la uretrolisis. En el único caso que está claramente indicada es en aquel donde, además de sintomatología obstructiva, existe incontinencia de esfuerzo (AU)

[Prolene mesh sling in the treatment of stress urinary incontinence. Integral treatment of pelvic floor anomalies. Long-term results]. / El sling de malla de prolene en el tratamiento de la incontinencia urinaria de esfuerzo. Tratamiento integral de las alteraciones del suelo pélvico. Resultados a largo plazo.

OBJECTIVES: To evaluate the results of a comprehensive treatment of female stress urinary incontinence combining prolene mesh sling and proper gynaecologic repair depending on the kind of prolapse or pelvic floor dysfunction. To analyse short and long term clinical and urodynamic outcomes, and the effect on quality of life and economics associated with female urinary incontinence. METHODS: Prospective study including 102 consecutive patients with urinary incontinence; recruitment started in June 1996, ended in March 2002 for this analysis but it continues open currently. History of neurourologic disorders, radiotherapy, oncological diseases, gynaecological diseases and previous surgeries data were recorded in all subjects. History and physical examination were done evaluating urinary symptoms, duration of urinary incontinence, and urinary symptoms oriented examination (incontinence, urgency and urgency-incontinence), as well as gynaecological examination evaluating and grading cystocele, rectocele, uterine prolapse, enterocele and dome prolapse. Complete urodynamics were performed before and after surgery. Surgery was indicated as a complete pelvic floor dysfunction repair including prolene mesh sling in all cases with urinary stress incontinence, hysterectomy or not depending on the existence of prolapse, and anterior/posterior colpoperineorrhaphy with or without mesh. Results on urinary continence, complications and their treatment were evaluated in the postoperative period, on discharge, at 6 months and yearly thereafter. RESULTS: Average age was 63.8 years (27-82 years, SD 11.2). 39.3% of the patients were over age 70. Mean follow-up was 4.25 years (12-75 months, SD 11.9). The cost of pads for urinary incontinence was 2741.17 Euros per patient (456,117 pesetas). 32.3% of the patients had risk factors for urinary incontinence surgical treatment failure and 18.8% had a leak point pressure below 30 H20 cm. 22.3% cases presented with detrusor instability before surgery. 102 sling procedures, 20 hysterectomies, 26 anterior plasties, 14 posterior plasties, 10 mesh cystocele repair, 1 posterior mesh, and 2 enterocele sacral promontory fixation were performed, accounting a total of 173 surgical procedures during 102 anaesthesia procedures. 9 additional procedures were necessary for the treatment of complications. Stress continence was achieved in 99.01% cases. In half of the patients with preoperative urgency-incontinence it continued during the first postoperative year. 11 cases have postoperative bladder instability, 7 of which had it preoperatively and 4 were de novo. COMPLICATIONS: 5 cases needed sling section/reconfiguration because of excess tension (non effective sling). 3 cases needed sling tight stretching/reconfiguration because of less than adequate tension. 2 cases of accidental bladder performation were treated with primary closure and urinary diversion. One case of infection-abscess in the mesh left anchoring stitch was drained under local anaesthesia. There were 6 cases of suprapubic, inguinal and rectal pain (8.1%), in all of them it disappeared within 9 months. There were 2 cases of wound infection. CONCLUSIONS: The prolene mesh sling can offer long term cure for stress urinary incontinence in almost all cases (99.01%), including the complicated ones. 91.1% of the patients underwent one surgical procedure only, and 8.8% required additional procedures. Results stand the test of time with a clinical-urodynamic follow up of 4.25 years. The voiding urgency referred by 81% of the women with large prolapses is associated with demonstrated bladder instability in 63% of the cases. Voiding urgency as well as bladder instability disappeared in all cases but one, being this fact prolapse-correction dependent, so that pelvic prolapse correction plays a decisive role. De novo bladder instability is uncommon (3.9%) and appears randomly in this series.

[Obstruction following surgical repair of female stress urinary incontinence. Diagnosis and treatment]. / Obstrucción tras cirugía correctora de la incontinencia femenina de esfuerzo. Diagnóstico y tratamiento.

OBJECTIVES: To report our experience in the diagnosis and treatment of the lower urinary tract obstruction after urinary incontinence corrective surgery, analysing the different techniques performed, retropubic or vaginal urethrolysis. METHODS: We report a series of 14 patients with the diagnosis of obstruction after incontinence corrective surgery. They were classified in 2 groups, those who underwent retropubic procedures (5 cases) and those who underwent prolene mesh sling procedures (9 cases). We detail preoperative clinical-urodynamic parameters, and postoperative bladder outlet obstruction confirmation. Retropubic urethrolysis was performed in all patients after retropubic surgery, with the association of hysterectomy if indicated. The performance of a new sling- urethropexy was individualized. In three cases of retropubic surgery repeated urethropexy was not done. Unilateral section was performed in the sling series for all except one case of double section. A new mesh sling was performed in two cases; two cases did not undergo reoperation. Urethrolysis results were evaluated both subjectively by satisfaction degree scales and objectively by clinical-urodynamic evaluation, comparing clinical data and urodynamic parameters using the proper statistical test. RESULTS: In the retropubic surgery group all patients are continent. Satisfaction degree is: very satisfied 3 patients and 2 quite satisfied. Two presented with voiding urgency not needing anticholinergic drugs, and their urodynamic data returned to normal values without post void residual. The obstructed patients in the sling group reported minimal urgency after urethrolysis in 2 cases. Two patients have stress urinary incontinence: one of them is better than before and refused to undergo a new operation; the other one, who repeated sling, developed a clinical picture of urgency-incontinence again, underwent second section and continues having stress urinary incontinence. Among 7 patients undergoing sling, 4 are very satisfied, 1 quite satisfied, 1 somewhat satisfied and 1 not at all satisfied. Voiding difficulties have disappeared in all cases; comparisons between pre and postoperative urodynamics maximum flow, detrusor pressure at maximum flow and postvoid residual show statistically significant differences. Post-urethrolysis parameters return to preoperative values. CONCLUSIONS: The immediate development of symptoms after surgical correction of urinary stress incontinence is the best diagnostic criteria for obstruction. Detrusor muscle responds to obstruction, but sometimes its response is so minimal that it is difficult to diagnose urodynamically. The knowledge of preoperative values helps to confirm the diagnosis. In any case, urodynamic parameters did not influence the success of urethrolysis. Urethrolysis is an effective operation to cure symptoms secondary to obstruction after incontinence corrective surgery. When a sling has been the procedure performed, probably it is not worth to perform a standard urethrolysis; a simple section of one of the branches seems to be enough to improve symptoms. Currently, there is not scientific evidence about the convenience or not of bladder neck-urethral re-suspension after urethrolysis. The only case-scenario in which it is clearly indicated is that when there is stress incontinence in addition to obstructive symptoms.

Enfermedad mestastásica de larga evolución en el adenocarcinoma renal. Afectación suprarrenal / Adrenal metastasis from renal cell carcinoma with long survival

OBJETIVOS: Exponer dos casos de enfermedad metastásica suprarrenal metacrónica (en un caso contralateral y en otro bilateral) por adenocarcinoma renal de células claras, con larga evolución cronológica de las recidivas. MÉTODO: Se analiza el curso durante 8 años de dos casos clínicos de enfermedad metastásica limitada por adenocarcinoma renal de células claras que desarrollaron metástasis suprarrenal, así como el seguimiento y las múltiples cirugías por metástasis única de las que han sido tributarios en este tiempo (3 por cada caso). Se analiza la indicación quirúrgica de la metástasis solitaria, la morbilidad, el pronóstico y se evalúan respecto a la literatura posibilidad de últimos tratamientos al efecto en estos casos, hoy en día aún en el ámbito de la investigación. RESULTADOS: La exéresis de la metástasis solitaria por el adenocarcinoma de células renales en estos casos ha proporcionado una supervivencia de más de 8 años con una buena calidad de vida. No se presentaron complicaciones quirúrgicas significativas. El pronóstico final es ominoso. CONCLUSIONES: En un caso, la demostración de no existencia de afectación linfática y la no extensión fuera del parénquima renal del tumor, no eximió de la aparición de metástasis única pulmonar cuatro años después, ni de afectación suprarrenal contralateral a los 8 años del diagnóstico inicial. En el otro caso, la infiltración de la vena renal en la exéresis del tumor primitivo nos ha de hacer pensar en la posibilidad a largo plazo de metástasis suprarrenal por su común asociación, demostrándose tres años después en la suprarrenal contralateral. La no realización de la suprarrenalectomía en la primera cirugía (tumor renal derecho de polo inferior) involucró metástasis suprarrenal a los 8 años del diagnóstico inicial. En ambos casos el pronóstico es infausto para el paciente y la situación desalentadora para el urólogo (AU)