[BCG and radiotherapy: the compatibility of 2 conservative treatments for cancer of the urinary bladder]. / BCG y radioterapia: compatibilidad de dos tratamientos conservadores frente al cancer de vejiga urinaria.

OBJECTIVE: To review the efficacy of radiotherapy and BCG in the treatment of transitional cell carcinoma of the urinary bladder in its different forms of presentation, with special reference to patients with infiltrating bladder tumors receiving radiotherapy and those in whom the lesion recurs as a high grade superficial bladder tumor. METHODS/RESULTS: 10 patients who previously received radiotherapy for T2-4 infiltrating bladder tumor that recurred as a high grade superficial tumor were treated with BCG. Four patients are alive and disease-free with a preserved bladder at 2-8 years follow-up. Four other patients who required cystectomy for persistence or progression of the tumor to the bladder wall, are alive and disease free at 3-7 years follow-up. The remaining two patients who were not amenable to major surgery died from the disease more than two years after treatment with BCG. BCG was well-tolerated by 70% of the patients and the rest showed minor complications. CONCLUSIONS: 28.3% of recurrences after radiotherapy are superficial tumors and 7% are carcinoma in situ. The appearance of carcinoma in situ or T1 G3 lesions following radiotherapy of the bladder questions its efficacy against these superficial forms for which cystectomy is reserved. BCG has been found to be effective in high grade superficial bladder tumors that have not been previously irradiated, therefore it would be acceptable to extend its application to those patients in whom radiotherapy has achieved control of the infiltrating tumor but not the high grade superficial tumor. The 40-70% of patients who are alive with a preserved bladder appears to be sufficient to recommend BCG salvage for high grade superficial bladder tumors post-radiotherapy. BCG therapy does not entail major complications or compromise patient survival, including those cases that will require cystectomy.

[Lumbar ureteral fistula after aortobifemoral bypass in a patient with ileal conduit and pelvic irradiation]. / Fístula ureteral lumbar después de un by-pass aortobifemoral en un paciente con conducto ileal e irradiación pélvica.

Contribution of a complex case of lumbar ureteral fistula with secondary abscess after aortobifemoral bypass in a patient with a background of radical cystectomy with ileal conduit and pelvic radiotherapy. A nephrostomy was established and the retroperitoneal collection was drained so that in a second phase ureteral replacement with ileum could be performed using uretero-ileal terminoterminal and ileum-ileal terminolateral by-pass with good therapeutic and functional results.

Incidence of tumoural pathology in horseshoe kidneys.

OBJECTIVES: To know the incidence of tumoural pathology among our cases of horseshoe kidney (HK), a congenital anomaly occurring in 0.25% of the population, as well as their prognostic factors and follow-up. METHODS: A total of 82 patients admitted at our Centre between 1967 and 1996 with an HK diagnosis were retrospectively reviewed. We have collected a total of 10 cases of HK tumours. We analyse the clinical, diagnostic, surgical and evolutionary peculiarities of the different HK tumour aetiologies, as compared with those described in literature. RESULTS: Our experience is based on 10 patients-5 adenocarcinomas, 4 transitional cell carcinomas and a Wilms' tumour. CONCLUSIONS: We have observed that in the case of transitional cell carcinomas, the diagnosis is generally made at an advanced stage. The prognosis of the tumorous disease depends upon the same prognostic factors as in the case of normal kidneys. Renal adenocarcinoma is the kind of tumour most frequently associated with HKs. Its incidence among the HK cases is not greater than among the normal population. Conservative local treatment criteria for adenocarcinoma should be valid for HKs as well.

[Orthotopic bladder substitution: II. Types and complications]. / Sustitución vesical ortotópica: II. Tipos y complicaciones.

OBJECTIVE: In the last two decades, attention has been focused on the design of continent urinary diversion and orthotopic neobladder in an attempt to find the ideal bladder substitute. The more commonly utilized techniques of orthotopic bladder replacement are described and the urodynamic aspects and complications are analyzed. METHODS: The series of Studer, Hautmann, Kock, Pagano, Thuroff (Mainz Pouch) and Goldwasser and the relevant literature on this subject were reviewed. RESULTS/CONCLUSION: To date, similar functional results have been achieved by the different techniques of bladder substitution, although different intestinal segments are utilized. A longer follow-up is warranted to determine which is the ideal technique of bladder substitution.

[Orthotopic bladder replacement: II. Functional results and complications in patients with Studer-type ileal neobladder]. / Sustitución vesical ortotópica: III. Resultados funcionales y complicaciones en los pacientes con neovejiga ileal tipo Studer.

OBJECTIVE: Since 1988, 100 Studer ileal low pressure urinary reservoirs have been performed at our institution. The functional results and the complications observed in these patients are presented. METHODS: Patients submitted to radical cystectomy and lower urinary tract reconstruction with the Studer technique from 1988 to 1994 were retrospectively studied. All patients were males, their mean age was 60 years (37-75) and the mean follow-up was 18 months (6-72). The isoperistaltic ileal segment as antireflux mechanism was utilized in 97 cases and intussusception of the ileal segment to which the ureters were anastomosed in 3 cases. Reinsertion of the ureter was done using the Wallace technique in 90 cases and by direct fixation according to a personal technique (H.V.) in 10 cases. Anastomosis of the neobladder and the urethra was done with the end of the second suture of the orthotopic reservoir. The neurovascular bands were preserved in 21 patients less than 60 years old with tumor stage T2-T3a, according to the technique described by Walsh and Mostwin (1984). RESULTS: One patient died early postoperatively from sepsis. The early complications included urinoma (4%), urinary fistula (3%), intestinal fistula (2%), pulmonary complications (4%), pelvic hematoma (1%) and intestinal obstruction (3%). Only 4 of these patients required surgical resolution of the complication. The late complications included stricture of neobladder-urethra anastomosis (6%), lithiasis in neobladder (4%), ureteroileal stricture (8%), 5 renal units were lost, chronic urinary retention (5%), symptomatic metabolic acidosis (1%) and urinary infection (14%). Thirteen of these patients with late complications required surgery. At 6 months' minimum follow-up, 90% of the patients were continent during the day and 60% during the night. Overall, 36% of the patients recovered erection postoperatively; 76% of the patients with preserved neurovascular bands recovered erection. Forty-four percent of the patients claimed they had a satisfactory sexual activity postoperatively. CONCLUSION: The Studer neobladder permits voiding through the urethra, preservation of the upper urinary tract, the urinary infection rate is acceptable, the complication rate is low and it offers patients continence rates that allow them to have a good quality of life.

[Orthotopic bladder replacement: I. Physiopathology of orthotopic bladder replacement with intestine]. / Sustitución vesical ortotópica: I. Fisiopatología de la sustitución vesical ortotópica con intestino.

OBJECTIVE: To analyze the physiopathological principles of utilizing the bowel for orthotopic bladder substitution and their effects on metabolism, function and continence. METHODS: The world literature is reviewed and our experience of 100 cases is described in the third part of this study. RESULTS/CONCLUSION: To reduce the metabolic changes, utilization of colonic or ileal segments with a maximum length of about 40 cm is advocated. This length of detubulized intestinal segment permits creating an ample, low pressure reservoir with an antireflux mechanism. The precise incidence of neoplastic degeneration of the ileal and colonic reservoirs is not known, but appears to be lower for the ileal neobladder.

[Vesico-ureteral reflux associated with detrusor instability]. / Reflujo vesicoureteral asociado a inestabilidad del detrusor.

OBJECTIVE: The aim of this study was to determine the urodynamic characteristics of patients with vesico-ureteral reflux (VUR) and detrusor instability (DI) followed by medical treatment. PATIENTS AND METHODS: The urodynamic and cystographic findings in a group of 24 patients between 4 and 18 years of age (mean 7.6 years) with a simultaneous diagnosis of VUR and DI were reviewed. All of them presented with recurrent urinary tract infections. Twenty were female of whom eight also had enuresis and daytime symptoms. Mean follow-up was 40 months (range 18-97 months). VUR was diagnosed by voiding cystourethrogram and classified according to the grades proposed by the "International reflux study on children". RESULTS: All but 6 patients had at least a 15% reduction in age-adjusted capacity. No relationship was observed between the severity of VUR (measured as the addition of reflux grades in both units of each patient) and reduction in bladder capacity or compliance. Seven patients had upper tract damage (either scars or a decrease in size or function on the renogram). Upper tract damage was significantly more frequent in patients with bilateral reflux (regardless of the type of DI). Patients with unilateral reflux and sustained instability had significantly less upper tract damage. Results of treatment are reported separately. CONCLUSIONS: In these patients, the severity of VUR did not seem to have an impact on bladder capacity or compliance. The risk factors for upper tract damage in this series differ from those found by other authors.

[Efficacy of oxybutynin chloride in children with vesico-ureteral reflux and detrusor instability]. / Eficacia del cloruro de oxibutinina en niños con inestabilidad del detrusor y reflujo vesicoureteral.

OBJECTIVE: The purpose of this study was to assess the urodynamic (UD), radiological (VCUG) and clinical outcome in patients with detrusor instability (DI) and vesico-ureteral reflux (VUR). PATIENTS AND METHODS: UD and VCUG findings in 24 patients between 4 and 18 years of age (mean 7.6 years) with a simultaneous diagnosis of VUR and DI were reviewed. All presented with recurrent urinary tract infections (UTI). Twenty were female of whom 8 also had enuresis and daytime symptoms. Ten had bilateral VUR, making a total of 34 units. Mean follow-up was 40 months (range 18-97 months) and at least 2 UD studies were done. Treatment consisted of oxybutinin chloride (OC) and chemoprophylaxis. RESULTS: Treatment lasted an average of 31 months with an average dose of 11 mg/day. There was a statistically significant improvement in UTI rate, enuresis score and UD parameters [CysCap, volume at 1st contraction, maximum contraction and compliance (comp)]. Thirteen patients achieved stable bladders and 9 had some UD improvement (3 with low compliance and 2 with less severe DI), leaving 2 with unchanged DI. Reflux disappeared in 20 units and was downgraded in 6. VUR improvement coincided with the cases of UD improvement. Persistence of DI was always associated with persistent VUR. CONCLUSIONS: Oxybutinin treatment can be long, but UD and VUR improvement run parallel in most cases. The rare discrepant cases point towards a multifactorial ethology in this condition.

[Urethral condyloma in the male: experience with 48 cases]. / Condilomas uretrales en el varón: experiencia en 48 casos.

OBJECTIVES: To review our experience in the diagnosis and treatment of urethral condylomata. METHODS: From June, 1977 to November, 1994, 64 patients with condyloma acuminatum were treated at our institution. Forty-eight cases who had received no previous treatment were analyzed. The main reason for consultation was the appearance of an exophytic lesion in the meatus. Most of the condylomata were located in the navicular fossa. Treatment was by electrocoagulation in 24 patients, photocoagulation with the Nd:YAG laser in 21 and other treatment modalities were utilized in 3 patients. To determine the incidence of recurrence and response to therapy, we analyzed the data of 34 patients with a minimum follow up of 2 months and a mean of 16 months. RESULTS: 36% had associated cutaneous condylomata. Urethroscopy detected 14.2% of the lesions that were undetectable by eversion of the meatus. Recurrence was observed in 35.2%. There were no differences for recurrence or complications between patients submitted to electrocoagulation and those who were treated by laser photocoagulation. CONCLUSIONS: Condyloma acuminatum of the urethra is uncommon. Urethroscopy is useful in making the diagnosis and for post-treatment follow up control evaluation. Electrocoagulation and Nd:YAG laser photocoagulation are useful in the treatment of this condition. Recurrence is frequently observed in patients with extensive lesions.

[Transitional cell carcinoma of the bladder: behavior in young adults]. / Carcinoma transicional de'vejiga: comportamiento en adultos jóvenes.

OBJECTIVES: Transitional cell carcinoma of the bladder is uncommon in the first three decades of life. Some authors claim that these age groups generally have low grade and superficial tumors. Our experience in the diagnosis and management of transitional cell carcinoma of the bladder in patients < or = 30 years old are analyzed. METHODS: The study comprised thirty-four patients (29 males and 5 females) who had been treated at the Fundación Puigvert from September, 1977 to November, 1993. RESULTS: Pathological analyses of the TUR and biopsy specimens showed most of the patients had low grade (88%) and stage (93%) tumors. The mean follow up was 66 months, range 12-168 months; 28 patients (83%) had a minimum follow-up of 12 months. Fourteen patients were stage Ta, 9 were T1, one T2, and there were 4 cases whose tumor stage could not be assessed (Tx). Tumor recurrence was observed in 9 of 28 patients (32%) and tumor progression in 1 patient. CONCLUSIONS: This tumor type is uncommon in patients < or = 30 years old. This age group generally has low grade/stage tumors. Although the incidence of tumor progression is low and these patients have a good prognosis, treatment and subsequent follow-up depend on tumor grade and stage at the time of diagnosis.

[Surgical treatment of fracture of the corpus cavernosum and the urethra: review of the literature and report of 2 cases]. / Tratamiento quirúrgico de la fractura de cuerpos cavernosos y uretra: revisión de la literatura a propósito de dos casos.

OBJECTIVES: Rupture of the corpora cavernosa, also known as fracture of the penis, is uncommon. To date, only 200 cases approximately have been reported. This lesion may be associated with rupture of the urethra in 25% of the cases. The diagnostic methods, management and the results achieved in these patients are discussed. METHODS: We describe two cases that had been treated at our institution and review the literature. RESULTS: Preservation of micturition and sexual function was achieved with early surgical management in these two patients with a follow-up of more than one year. CONCLUSIONS: An associated urethral lesion should be strongly suspected in the presence of urethrorrhagia. A negative urine sediment discards the presence of this lesion. If urethral injury associated with penile rupture is suspected, low pressure urethrography is the diagnostic method of choice following sonographic evaluation of the corpora cavernosa. Cavernosal integrity can only be established by cavernosography in equivocal cases and is not required when extravasation is demonstrated by urethrography. Conservative management carries a high risk of penile curvature and painful erection; therefore, whenever possible, surgery should be performed within a few hours following trauma and after careful evaluation. The cavernosal defect is repaired and end-to-end anastomosis of the urethra is performed. The patient should be informed of the risk of painful erection, penile curvature and urethral stenosis.

[Evolutive orchiepididymitis or ischemic testis?: that is the question]. / Orquioepididimitis evolutiva o testículo isquémico?: he ahí la cuestión.

We report a case of deferred acute scrotum in a young teenager. Even though initially the aetiological diagnosis seemed clear (partially treated epididymo-orchitis), glandular viability remained uncertain due to ultrasound findings and the time elapsed since initial diagnosis. Colour Doppler Ultrasound is examined as the most useful ancillary method in differential diagnosis in this setting, as well as the different ultrasound findings in subsequent stages of spermatic cord torsion and epididymo-orchitis. Possible testicular ischaemia in this clinical setting is emphasized, explaining its pathophysiology.

[Analysis of 895 consultations for hematuria in the emergency department in an urology unit]. / Analyse de 895 consultations pour hématurie dans le département des urgences d'un service d'urologie.

OBJECTIVE: To study efficacy of our diagnostic approach in patients with haematuria, as well as the information provided by the different tests. PATIENT AND METHODS: The computerization of our emergency department, and the study of the data base have permitted us to study retrospectively 722 cases of hematuria seen at our center over a period of 10 months. The relation between the benign or malignant etiology of the hematuria, and the presence or absence of associated symptoms and the intensity of the hematuria is shown, as well as the relation between the intensity of the hematuria and the decrease in the hemoglobin rates detected. RESULTS: Fifty eight percent of the 722 patients, 39% of them due to neoplasm. The intensity of had one symptom only hematuria was significantly superior in the patients with the final diagnosis of neoplams. The accomplishment of reactive strip, basic imaging techniques and urine sediment has permitted in our series to direct the diagnosis in 67.3% of patients. Cystoscopy has shown great efficacy in diagnosing the cases of monosymptomatic hematuria with normal radiological studies. CONCLUSION: Monosymptomatic hematuria deserves a work-up to rule out malignancy. Reactive strip, urine sediment, KUB and ultrasonography allow to direct the diagnosis in most cases.

[The use of the IPSS questionnaire in surgical patients. International Prostatic Symptom Score]. / Uso del cuestionario IPSS en pacientes operados.

Some feasibility problems were detected during the evaluation of the IPSS questionnaire in Spanish that might limit its application. Our initial experience with the IPSS in patients undergoing surgery had 3 aims: 1) assess if changes in format and wording will improve feasibility; 2) evaluate symptoms before and after surgery according to the patients' point of view and 3) determine possible predictive factors of bad outcome in patients undergoing surgery for BPH. 50 patients were included and 35 completed symptom and urolow evaluation before and after the intervention. First objective: a modified format improved feasibility up to 92% (from 49% with the original format). Second objective: 7 patients had a poor symptomatic outcome (either worsened or had an unsignificant improvement), but only one of them had a low postoperative Qmax. Third objective: patients with preoperative urinary retention had a worse urodynamic outcome, but most improved in their symptoms. Worse symptomatic results occurred in: a) patients with a IPSS score smaller than 13 and b) patients undergoing transurethral incision of the prostate. The results are presented both in global (comparison of mean values) and in an individualized manner to call upon the pitfalls in their interpretation.

[The IPPS questionnaire in patients and controls. Psychometric validation]. / Cuestionario IPSS en pacientes y controles. Validación psicométrica.

The translation into Spanish of the AUA/International Prostatic Symptom (AUA/IPS) Score hadn't been validated in spanish. METHODS. AUA/IPS questionnaire was self administered by 103 consecutive patients and by 24 healthy volunteers. An alternative formulation to question 4 (ALT-4) was added. RESULTS. 51 patients (49%) and 17 controls (79%) completed al questions (Feasibility). Reliability was measured by: a) Crohnbach's alpha (0.68 and 0.70 with ALT-4) b) Kendall's coefficient of concordance (0.097, significance < 0.001) and c) retesting 17 patients within 2 months. The relation of the AUA/IPS scores with quality of life (Construct validity) showed a Spearman's correlation coefficient of 0.57 (confidence = 0.0001), and 0.52/0.0004 with ALT-4. The relation with uroflowmetry (Concurrent empirical validity) was poor as shown in ROC curves. CONCLUSIONS. The Spanish version of the AUA/IPS questionnaire given in an easy format improves feasibility without alteration of reliability or validity. The relation of the AUA/IPS score with uroflowmetry is poor, although the questionnaire can be considered valid and reliable.

[The effects of verapamil in experimental acute pancreatitis in the rat]. / Efectos del verapamil en la pancreatitis aguda experimental de la rata.

Experimental studies have shown that verapamil inhibits pancreatic exocrine secretion. In order to determine whether verapamil has any effect on acute pancreatitis (AP), we undertook an experimental study in Wistar rats. We used 72 animals divided into two groups. In all animals of both experimental groups, AP was induced by ligation of the biliary duct at its entrance in the duodenum. Animals were given saline (NaCl 0.9%), or 0.30 mgrs/hour verapamil. Subgroups of 9 animals, were treated for 6, 12, 18 and 24 hours; 6 animals group were then sacrificed, for biochemical studies (serum amilase, lipase, and calcium; and trypsin and chemotrypsin in the homogenized pancreas); the other 3 animals were used for morphologic study of the pancreas. Verapamil treatment decreased significantly tissue activity of trypsin (p less than 0.001) and chemotrypsin (p less than 0.0001) and increased serum lipase (p less than 0.05), and calcium. There was no statistical difference in serum amylase. Morphological findings include oedema, acinar necrosis, hemorrhage and vasculitis in non treated animals. Only oedema was observed in animals treated with verapamil. These results suggest a beneficial effect of verapamil on experimental AP induced by ligation of the bile duct in the rat.

[Biochemical and functional changes in experimental acute pancreatitis in the rat]. / Alteraciones bioquímicas y funcionales de la pancreatitis aguda experimental de la rata.

To discover the biochemical alterations occurring in the first 24 hours of acute pancreatitis (PA), we made an experimental study using rats. We used 90 animals in which necrosis and hemorrhage were induced by closing the choledochus. Animals underwent evolutive periods of 1, 2, 3, 4, 5, 6, 12, 18 and 24 hours. They were sacrificed and plasma (to determine amylase, lipase, creatinine and calcium), urine (amylase and creatinine), ascitic and pleural liquid (amylase and lipase) were obtained from 6 animals of each evolutive period. We made a post-mortem study of the pancreas of three animals of each subgroup. There was a significant increase in the amylasemia from the third hour (p less than 0.005) and of plasmatic lipase from the first hour (p less than 0.0001). Creatinine values remained in normal range and calcemia fell after the sixth hour (p less than 0.001). There was an increase in amylase concentration in urine and in ascitic and pleural liquids, and of the lipase in the last two. These changes correlated with the duration of the disease and with the histologic changes of the gland, which consist in edema, acinar necrosis, vasculitis and hemorrhage, which are present from the first hour and increase as time passes.